Encyclopedia of Drug

ADDICTIVE BEHAVIOR ENCYCLOPEDIA of DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR Editorial Board EDITOR IN CHIEF Rosalyn Carson-DeWitt, M.D. Durham, North Carolina

EDITORS Kathleen M. Carroll, Ph.D. Associate Professor of Psychiatry Yale University School of Medicine Jeffrey Fagan, Ph.D. Professor of Public Health Joseph L. Mailman School of Public Health, Columbia University Henry R. Kranzler, M.D. Professor of Psychiatry University of Connecticut School of Medicine Michael J. Kuhar, Ph.D. Georgia Research Alliance Eminent Scholar and Candler Professor Yerkes Regional Primate Center ADDICTIVE BEHAVIOR ENCYCLOPEDIA of DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR

SECOND EDITION

VOLUME 3 R – Z

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Library of Congress Cataloging-in-Publication Data Encyclopedia of drugs, alcohol, and addictive behavior / Rosalyn Carson-DeWitt, editor-in-chief.–Rev. ed. p. cm. Rev. ed. of: Encyclopedia of drugs and alcohol. c1995. Includes bibliographical references and index. ISBN 0-02-865541-9 (set) ISBN 0-02-865542-7 (Vol. 1) ISBN 0-02-865543-5 (Vol. 2) ISBN 0-02-865544-3 (Vol. 3) ISBN 0-02-865545-1 (Vol. 4) 1. Drug abuse–Encyclopedias. 2. Substance abuse–Encyclopedias. 3. Alcoholism–Encyclopedias. 4. Drinking of alcoholic beverages–Encyclopedias. I. Carson-DeWitt, Rosalyn II. Encyclopedia of drugs and alcohol. HV5804 .E53 2000 362.29'03–dc21 00-046068 CIP

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RACIAL PROFILING ‘‘Profiles,’’ formal percent of those stopped and searched on New Jer- and informal, are common in law enforcement, sey highways are African American or Hispanic, particularly in narcotics law enforcement. They even though, according to one expert, only 13.5 consist of general characteristics and features that percent of the drivers and 15 percent of the might make a law enforcement officer suspicious. speeders on those highways are African American In some instances, law enforcement agencies for- or Hispanic. An Orlando Sentinel analysis of 1,000 mulate and disseminate formal profiles to officers videotapes of Florida state trooper traffic stops in to guide their investigative actions. Even when pro- 1992 showed that on a road where 5 percent of the files are not formally maintained, however, officers drivers were African American or Hispanic, 70 per- inevitably rely on their past experience to generate cent of those stopped and 80 percent of those informal profiles for whom to follow more closely, searched by the Florida state police were African approach, stop, or question. There is nothing American or Hispanic. wrong with profiling as a general practice, but Racial targeting need not be expressly invited by when race becomes a factor in a profile, serious constitutional and ethical issues arise. a profile. Consider, for example, the U.S. Drug Racial profiling is the use of racial generaliza- Enforcement Agency’s (DEA) drug courier profile tions or stereotypes as a basis for stopping, search- for airports. All the factors listed below have been ing, or questioning an individual. Racial profiling identified by DEA agents in court testimony as part received a great deal of attention in the United of the DEA’s drug courier profile: States in the late 1990s as a result of a series of arrived late at night prominent incidents and the release of data on po- arrived early in the morning lice practices from several jurisdictions. The data consistently showed that African Americans and arrived in afternoon Hispanics are disproportionately targeted by law one of first to deplane enforcement for stops, frisks, and searches. Court one of last to deplane records showed, for example, that in Maryland Af- deplaned in the middle rican Americans made up 70 percent of those bought coach ticket stopped and searched by the Maryland State Police bought first-class ticket from January 1995 through December 1997, on a used one-way ticket road on which 17.5 percent of the drivers and use round-trip ticket speeders were African American. A 1999 report by paid for ticket with small denomination cur- the New Jersey Attorney General found that 77 rency

947 948 RACIAL PROFILING

paid for ticket with large denomination cur- sions (either because there was no arrest or indict- rency ment, or because the defendant pleaded guilty)— made local telephone call after deplaning the statistics are so one-sided as to raise serious made long-distance telephone call after questions about racial targeting. deplaning Although statistical data alone do not conclu- pretended to make telephone call sively establish that officers are engaged in ‘‘racial traveled from New York to Los Angeles profiling,’’ they provide strong circumstantial evi- traveled to Houston dence. Many police officers, moreover, admit that carried no luggage all other things being equal, they are more suspi- carried brand-new luggage cious of, for example, young African-American carried a small bag men than elderly white women. Nor is such think- carried a medium-sized bag ing irrational. Criminologists generally agree that carried two bulky garment bags young African-American men are more likely to carried two heavy suitcases commit crime than elderly white women, because carried four pieces of luggage at least with respect to some crime, young people overly protective of luggage commit more crime than old people, men commit disassociated self from luggage more crime than women, and African Americans traveled alone commit more crime than whites. Indeed, it is pre- traveled with a companion cisely because the use of race as a generalization is acted too nervous not irrational that racial profiling is such a wide- acted too calm spread phenomenon. made eye contact with officer In some areas, however, there is evidence that avoided making eye contact with officer the use of racial profiles is irrational. The strongest wore expensive clothing and gold jewelry evidence is with respect to drug law enforcement. dressed casually Much of the racial profiling that occurs on the na- went to restroom after deplaning tion’s highways is conducted for drug law enforce- walked quickly through airport ment purposes. Officers use the pretext of a traffic walked slowly through airport infraction to stop a car and then ask for consent to walked aimlessly through airport search the car for drugs. This tactic has been ex- left airport by taxi pressly approved by the U.S. Supreme Court. left airport by limousine Yet studies show that officers get virtually the left airport by private car same ‘‘hit rates’’ for whites and African Americans left airport by hotel courtesy van when they conduct traffic stops for drugs. In other suspect was Hispanic words, officers are no more likely to find drugs on suspect was African-American female an African-American driver than a white driver. Consistent with these results, the U.S. Public Even without the last two factors, this profile Health Service has found, based on confidential describes so many travelers that it does not so much self-report surveys, that African Americans and focus an investigation as provide DEA officials a whites use illegal drugs in rough proportion to their ready-made excuse for stopping whomever they representation in the population at large. In 1992, please. A Lexis review of all federal court decisions for example, 76 percent of illegal drug users were from January 1, 1990 to August 2, 1995, in which white and 14 percent were African American. Since drug courier profiles were used and the race of the most users report having purchased drugs from a suspect was discernible, revealed that of sixty-three dealer of the same race, drug dealing is also likely such cases, all but three suspects were minorities: to be fairly evenly represented demographically. thirty-four were African-American, twenty-five Thus, the supposition that African Americans are were Hispanic, one was Asian, and three were more likely to be carrying drugs is sharply contra- white. While this is not a scientific sampling—it dicted by the data. does not include cases in which the race of the In any event, even where demographic data sug- suspect could not be discerned, and it does not gests that the practice of racial profiling may not be include cases that did not result in judicial deci- irrational, it is both unconstitutional and unwise. RATIONAL AUTHORITY 949

Because of the pernicious history of racial classifi- lating that racial profiling is impermissible: Pre- cations in the United States, the Supreme Court cisely because racial profiling is deeply embedded forbids official reliance on racial generalizations— in the culture and not always irrational, police even accurate ones—except when there is no other officers are likely to continue to do it unless the way to achieve a compelling government end. The practice is clearly prohibited. And the third step usual argument police officers advance in defense will require effective monitoring and discipline. It of profiling is that it recognizes the unfortunate fact remains to be seen whether racial profiling can be that minorities are more likely than whites to com- halted effectively. mit crime. But while this may be true with respect to some crimes, the generalizations are hopelessly BIBLIOGRAPHY overinclusive even as to those crimes. The fact that African Americans are more likely than whites to COLE, D. (1999). No equal justice: Race and class in the engage in violent crime, for example, does not American criminal justice system. New York, NY: New mean that most African Americans commit violent Press. crime. Most African Americans, like most whites, HARRIS, D. (1999). Driving while black: Racial profiling do not commit any crime; annually, at least 90 on our nation’s highways. New York, NY: American percent of African Americans are not arrested for Civil Liberties Union. anything. On any given day, the number of inno- HARRIS, D. (1999). The stories, the statistics, and the cent African Americans is even higher. In addition, law: Why driving while black matters, Minnesota Law when officers focus on minorities, they lose sight of Review, 84(2), 265–326. white criminals. Race is a terribly inaccurate indi- DAVID D. COLE cator of crime. Most important, relying on race as a factor for suspicion violates the first principle of criminal law: individual responsibility. The state’s authority to RATIONAL AUTHORITY Drug addicts take its citizens’ liberty, and in extreme cases, lives, are reported to have a low tolerance for ANXIETY. turns on the premise that all are equal before the As a result, few are able to voluntarily sustain an law. Racial generalizations fail to treat people as extended period of drug treatment, which is neces- individuals. As a result, policies that tolerate racial sary for meaningful intervention. Instead, they tend profiling undermine the criminal law’s legitimacy. to disengage themselves from treatment programs As any good leader knows, and many crimino- once the anxiety has been brought to the surface logists have confirmed, legitimacy is central to get- (Brill & Lieberman, 1969). ‘‘Rational authority,’’ a ting people to follow the rules. If people believe in late 1960s euphemism for mandatory (but not nec- the legitimacy and fairness of the system, they are essarily punitive) treatment, became a basis for much more likely to abide by the rules than if they holding addicts in a long-term treatment program. see the system as unjust. Thus, racial profiling may The philosophy behind rational authority jus- indeed contribute to crime by corroding the legiti- tifies the development of coercive mechanisms or macy of the criminal law. strategies that permit assigning to treatment those Efforts to halt racial profiling are now in place in addicts who ordinarily would not voluntarily seek many American jurisdictions. In 1999, President assistance. Rehabilitation programs based upon Clinton ordered all federal agencies to study their this philosophy derive their legitimate coercive law enforcement practices to root out racial pro- powers through the authority of the courts. The filing, and several states and cities—including authority is considered rational because it is uti- North Carolina, Connecticut, Florida, Houston, lized in a humane and constructive manner, and it and San Diego—have required reporting on the does this by relating the means of authority to the racial patterns of law enforcement. Such reporting ends of rehabilitation. is the first step toward ending the practice, because This conceptualization represents an evolution- as long as records of police practices are neither ary change from the emphasis on the use of author- kept nor made public, the nature and extent of the ity as a punitive end in itself. Rational authority problem will be hidden. The second step requires also suggests combining the authority of the proba- clear statements by law enforcement officials stipu- tion or parole officer with the techniques of social 950 RATIONAL RECOVERY (RR) casework. As such, authority becomes a means for An RR ‘‘coordinator’’ leads a group of five to the officer or associated rehabilitation worker to ten members, who meet once or twice weekly for implement desired behavioral changes. In addition ninety minutes. Each coordinator maintains con- to being required to obey the usual conditions of tact with an adviser, a mental-health professional probation, addicts can be involuntarily held in a familiar with the RR program. RR emphasizes therapeutic setting until they have acquired a toler- cognitive devices for securing abstinence, such as ance for abstinence and the conditioning processes discussion of ‘‘the Beast,’’ a term used to personify thought to maintain addiction have been reversed. the compulsive thoughts that drive an individual Evaluations of programs in New York, California, to drink. Members use a ‘‘Sobriety Spreadsheet’’ and Pennsylvania that are based upon rational on which they write out irrational beliefs that acti- authority indicate that when addicts are thus su- vate their desire to drink. They also read pervised, they are often less likely to relapse into Trimpey’s The Small Book to develop the proper addictive behavior (Brill & Lieberman, 1969). attitude toward abstinence. These devices are used in RR meetings as well as outside to examine vulnerability to drinking and to overcome it. At meet- (SEE ALSO: California Civil Commitment Program; ings these issues are also addressed in a less formal Civil Commitment; Coerced Treatment for Sub- way in ‘‘cross-talk,’’ an open, face-to-face ex- stance Offenders; Contingency Management; New change among participants. York State Civil Commitment Program; Treatment RR differs from AA in that it does not encourage Alternatives to Street Crime Treatment/Treatment supportive exchanges and phone calls between Types) meetings, nor does the enrollee solicit a sponsor among established members. Also in contrast to BIBLIOGRAPHY AA, there is no equivalent of ‘‘working’’ the TWELVE STEPS, and a spiritual or religious orienta- BRILL, L., & LIEBERMAN, L. (1969). Authority and addiction to treatment is explicitly eschewed. Like SECU- tion. Boston: Little, Brown. LAR ORGANIZATIONS FOR SOBRIETY (SOS), RR en- LEUKEFELD,C.G.,&TIMS,F.M.(EDS.). (1988). Com- courages study of its methods and outcome. One pulsory treatment of drug abuse: Research and clini- such study by Galanter and coworkers sent fol- cal practice (NIDA Research Monograph 86). Rock- low-up questionnaires to seventy RR groups in ville, MD: U.S. Department of Health and Human nineteen states and received sixty-three responses. Services. Ninety-seven percent of participants in the re- HARRY K. WEXLER sponding groups filled out questionnaires. They were mostly men about forty-five years old, each with about a twenty-five-year history of alcohol problems. The majority were employed, had at- RATIONAL RECOVERY (RR) Rational tended college, and had heard about the program Recovery (RR) is one of a number of self-help through the media or by word of mouth. A majority movements that have emerged as alternatives to had used marijuana, a substantial minority had ALCOHOLICS ANONYMOUS (AA) for those with drug also used cocaine, and a small minority had used and alcohol problems. Rational Recovery began heroin. with the publication of Rational Recovery from Al- At the time of the study (the early 1990s), RR coholism: The Small Book by Jack Trimpey in was a much younger organization than AA. Most of 1988. The program is based on Rational Emotive the coordinators had been members for only nine Therapy, a mental-health treatment with a cogni- months, most groups had been meeting for about a tive orientation developed by the psychologist year, and the implementation of the movement’s Albert Ellis. It is premised on the assumption that specific techniques (use of the Sobriety Spreadsheet psychological difficulties are caused by irrational and discussion of ‘‘the Beast’’) was not consistent. beliefs that can be understood and overcome, not Nevertheless, the members’ commitment to the by existential or spiritual deficits. The emphasis is central tenet of the movement, sobriety, was con- on rational self-examination rather than on siderable. Although 75 percent had previously at- religiosity. tended AA meetings, the majority (82%) rated RR RAVE 951 principles higher than AA principles in helping them achieve sobriety. However, it seems quite likely that RR benefits considerably from the experience these former AA members bring with them. A sizable percentage of RR participants who returned questionnaires were involved with mental- health care as well as with RR. Thirty-six percent had seen a psychotherapist the week before the survey, and 21 percent were currently taking medication prescribed for psychiatric problems. Many group coordinators had formal mental-health training, and 24 percent had graduate degrees or certificates in mental health. It is likely that, just as AA derives some legitimacy from its spiritual roots, Dancers take to the crowded, smoky dance floor RR derives some of its influence from the credibility at an all-night rave at Groove Jet in Miami of the professional psychology with which it is asso- Beach, September 24, 1999. (AP Photo/Greg ciated. Without carefully controlled studies that Smith) adjust for differences in patient backgrounds, it is hazardous to compare outcome studies from RR to the late 1980s when all-night parties and Detroit studies of AA and other self-help groups. The data techno music sprang up in the United Kingdom to that do exist, however, tentatively suggest that RR form the phenomenon that is still a social concern may do at least as well. today. Raves are held in a variety of locales, from An RR group can be formed at no cost by a traditional nightclubs to warehouses to open pas- recovering substance abuser in consultation with tures (sometimes without the knowledge of the the executive office of the Rational Recovery move- owners). A major part of the attraction of raves is ment (Box 800, Lotus, California 95651). the permissive, underground atmosphere. Ravers, who are more often than not in their late teens and (SEE ALSO: Sobriety; Treatment Types: Self-Help and Anonymous Groups) early twenties, enjoy the freedom from supervision that is common at raves. Hedonism or ‘‘pleasure seeking’’ is also of cen- BIBLIOGRAPHY tral value in rave culture, and this correlates with a GALANTER, M., EGELKO, S., & EDWARDS, H. (1993). high incidence of drug use. Many ravers freely ad- Rational Recovery: Alternative to AA for addiction? mit to the presence of various clubdrugs on the American Journal of Drug and Alcohol Abuse 19, rave scene, particularly METHAMPHETAMINE (meth, 499–510. crank, crystal, speed or whizz) and MDMA (E, X, GELMAN, D., LEONARD, E. A., & FISHER, B. (1991). Clean ecstasy, or rolls) although others such as and sober and agnostic. Newsweek, July 8, pp. 62–63. ROHYPNOL,GHB,LSD, and KETAMINE have recently TRIMPEY, J. (1988). Rational recovery from alcoholism: gained more attention in the media as clubdrugs. The small book. Lotus, CA: Lotus Press. In truth, polydrug abuse is common enough on the MARC GALANTER rave scene that no list of drugs can be regarded as comprehensive. Ravers tend to regard the drugs they use as newer and safer than ‘‘older’’ drugs like RAVE A rave is a large, typically overnight HEROIN and PCP. This is rarely true insofar as dance party with a focus on techno and related safety is concerned. Raves have certainly seen their forms of music. The rave provides a venue for inno- share of drug casualties, and are cause for concern vative musical forms and fashions as well as for the use and abuse of a variety of drugs known collec- because of the high incidence of drug problems tively as CLUB DRUGS. Raves and the ‘‘ravers’’ who among ravers. attend them have been a part of youth culture since RICHARD G. HUNTER 952 RECEPTOR, DRUG

RECEPTOR, DRUG A receptor is a molecu- GLUTAMATE, binds to this protein, the central pore lar site, specific for a drug or its class, with which of the NMDA receptor channel opens—then cations the drug must combine to produce its effect. If a (the ions of sodium, potassium, and calcium) are drug is in the body but cannot bind to the receptor, able to cross the cell membrane. The movement of then there is no effect. A receptor can be thought of cations through the pore results in neuronal as the button or switch that the drug must activate excitation. in order to produce a physiologic effect. The NMDA receptor is one of several cell recep- Receptors for drugs are the same receptors used tor surface proteins activated by glutamate. The in the brain by naturally occurring compounds re- HALLUCINOGEN PHENCYCLIDINE (PCP) blocks the ferred to as neurotransmitters. NEUROTRANSMIT- open channel of the NMDA receptor preventing TERS are chemical signaling messengers in the brain cation flow. It is believed that overactivation of the that work by binding to specific receptors; a wide NMDA receptor could be responsible for the neuro- variety of drugs of abuse bind to these same recep- nal cell death observed following some forms of tors. In this sense, drugs of abuse insert themselves stroke; it may even be involved in the cell death into natural and normal systems found in the brain associated with neurodegenerative diseases. take over normal pathways in abnormal ways. Re- ceptors are essential for normal functioning of the (SEE ALSO: Neurotransmission; Receptor; Drug) body and are, therefore, of great interest and importance in physiology and medicine. BIBLIOGRAPHY Receptors can be stimulated by compounds CHOI, D. (1988). Glutamate neurotoxicity and diseases of called AGONISTS, or blocked by compounds called the nervous system. Neuron, 1, 623–634. ANTAGONISTS. Antagonists prevent the action of COLLINGRIDGE, G., & LESTER, R. (1989). Excitatory agonists. For example, NALTREXONE, an antago- amino acid receptors in the vertebrate central nervous nist, will prevent MORPHINE, an agonist, from having any effect. system. Pharmacology Reviews, 40(2), 145–210. A major achievement of research in drug abuse MAYER, M. L., & WESTBROOK, G. L. (1987). The physiol- over the past thirty years has been the identification ogy of excitatory amino acids in the vertebrate central and study of almost all receptors for drugs of abuse. nervous system. Progress in Neurobiology, 28, 197– Receptors are generally classified into two types: an 276. ion channel type and a coupled type receptor or ‘‘G GEORGE R. UHL protein’’. NICOTINE acts at one of the former and VALINA DAWSON morphine at one of the latter. However, sometimes the initial molecular site that a drug acts at is not See Relapse; Relapse Preven- one of these two classical types of receptors. For RECIDIVISM tion example, COCAINE acts at another kind of molecule called a transporter for DOPAMINE; after cocaine binds at this site, dopamine transport in the brain is RECREATIONAL DRUG USE See blocked, which then results in increased actions at Addiction: Concepts and Definitions; Policy Alter- the dopamine receptor. Since receptors are the ini- natives; Safer Use of Drugs tial, molecular sites of binding of drugs, they are clearly of interest in understanding how drugs produce their effects and how we might develop medi- REINFORCEMENT Although the term re- cations for drug abuse treatments. inforcement has many common uses and associated NICK E. GOEDERS meanings, its meaning is precise when used by be- REVISED BY MICHAEL J. KUHAR havior analysts and behavior therapists. The act or process of making a reinforcer contingent on behavior is termed positive reinforcement, and a rein- RECEPTOR: NMDA (N-METHYL forcer is any object or event that, when delivered D-ASPARTIC ACID) The NMDA receptor is a following some behavior, increases the probability protein on the surface of neurons (nerve cells). that the behavior will occur again. A typical exam- When the major excitatory NEUROTRANSMITTER, ple might evolve from a laboratory experiment with REINFORCEMENT 953 rats. A rat is placed in a small plastic chamber. The driven syringe. The animal can press a lever to rat can press a lever located on one wall of the activate the pump, and this results in a dose of a chamber. When the rat presses the lever, a small drug such as COCAINE,HEROIN,NICOTINE,or food pellet drops into a dish. If the rat returns to the ALCOHOL being infused into the vein. If the animal lever and continues to press it would be said that continues to press the lever to obtain the drug, then the food pellet functions as a reinforcer that the the drug is said to serve as a reinforcer. Interest- behavior is maintained by positive reinforcement. ingly, those drugs which lead to ADDICTION in hu- There is often confusion between positive rein- mans also serve as reinforcers in animals. The only forcement and negative reinforcement. Negative exception is MARIJUANA (THC),which is used fairly reinforcement occurs when a behavior results in extensively by humans but does not function as a terminating an aversive stimulus. In the case of the reinforcer in animals. It should be noted that drugs rat, the negative stimulus might be a loud noise. A that serve as reinforcers under one condition may lever press turns off the stimulus. If the rat contin- not serve as reinforcers under other conditions. For ues to press the lever, it would be said that loud example, nicotine serves as a reinforcer only at low noise functions as a negative reinforcer and the doses and when doses are properly spaced. Never- behavior is maintained by negative reinforcement. theless, the observation that drugs of abuse gener- Thus, both positive and negative reinforcement ally function as reinforcers in experimental animals refer to increases in behavior, but differ in whether has brought the study of drug-seeking behavior a pleasant stimulus is presented as the result of and drug abuse into a framework that allows care- some behavior (positive reinforcement). Negative fully controlled behavioral analyses and the appli- reinforcement is also referred to as escape (if the cation of well-established and objective behavioral response turns off the stimulus each time it ap- principles (Schuster & Johanson, 1981). pears) or avoidance (if the response can postpone The acquisition of drug use in humans predomi- presentation of the stimulus). nantly involves positive reinforcement, whereas the It is important to note that reinforcement is a maintenance of drug use can involve both positive concept that refers to the relationship between be- and negative reinforcement. The ability of a drug to havior and its consequences. Stimuli or events are serve as a positive reinforcer is usually associated not assumed to have inherent reinforcing effects. with its pleasurable subjective effects (e.g. a For example, although most people like money and ‘‘rush’’, a ‘‘high’’, or other feelings of intoxication). will continue to exhibit behavior that results in But again, given the definition of reinforcement, it obtaining money, it cannot be assumed that money is not necessary for a drug to be subjectively rein- functions as a reinforcer for everyone. For example, forcing or pleasurable in order for it to maintain money might not serve as a reinforcer for a monk behavior. Many drugs are also associated with devoted to an ascetic lifestyle. The defining charac- symptoms of WITHDRAWAL when abstinence is ini- teristic of reinforcement depends on how a behav- tiated following a period of regular use. In this case, ior is changed and not on the types of things that taking the drug again may terminate the aversive serve as reinforcing events (Morse & Kelleher, state of withdrawal; in this way, drug use is main- 1977). Factors that help determine whether a given tained by negative reinforcement. Drug use can object or event is reinforcing or punishing for a also be influenced by sources of reinforcement given individual include that individual’s previous other than the direct effects of the drug. For exam- experiences and other features of the environment ple, social encouragement and praise from a peer that coexist and are associated with the object or group can play an important role in the develop- event. The upshot is that different things may func- ment of drug use by teenagers. Biological factors tion as reinforcers for different people. may also come into play. For example, some indi- DRUGS can serve as reinforcers that maintain viduals may be more or less susceptible than others drug-seeking and drug-taking behaviors. This can to feeling and recognizing the pleasurable effects of be observed in the prevalence of drug use among drugs. When drug use is viewed as a behavior humans and has also been shown in laboratory maintained by the reinforcing effects of drugs, it research with animals. In a typical laboratory ex- suggests that this behavior is not amoral or uncon- periment, the animal such as a rat or monkey has a trolled but rather that it is the result of normal catheter placed in a vein and connected to a pump- behavioral processes. 954 RELAPSE

(SEE ALSO: Addiction: Concepts and Definitions: behavioral model. According to this model, individ- Causes of Substance Abuse: Learning; Research, uals experience an increased risk of relapse when Animal Model: Intercranial Self-Stimulation; they encounter so-called high-risk situations, Wikler’s Pharmacologic Theory of Drug Addiction) which are situations that have been associated with substance use in the past. The model postulates BIBLIOGRAPHY that one of two processes occurs when a substance abuser encounters a high-risk situation. If the indi- MORSE, W. H., & KELLEHER, R. T. (1977). Determinants vidual has high self-efficacy, or the belief that he or of reinforcement and punishment. In W. K. Honig & she can manage the situation without using alcohol J. E. R. Staddon (Eds.), Handbook of operant behav- or drugs (i.e., relapsing), a coping response is perior. Englewood Cliffs, NJ: Prentice Hall. formed and relapse is avoided. However, if the SCHUSTER, S. R., & JOHANSON, C. E. (1981). An analysis individual has lower self-efficacy, a coping re- of drug-seeking behavior in animals. Neuroscience sponse is not performed and relapse ensues. There- and Biobehavioral Reviews, 5, 315–323. fore, in this model relapse is seen largely as a MAXINE STITZER function of whether one (1) encounters high-risk situations, and (2) is able to mount an effective coping response. Other cognitive features of the model include outcome expectancies (i.e., what will RELAPSE An individual who has recovered happen as a result of either substance use or the from an illness or has entered a period of stability in exercise of a coping behavior) and attributions for a chronic illness and who subsequently suffers a one’s behavior. recurrence of symptoms is said to have experienced Related models of relapse, which encompass en- a relapse. In the addictions, there has been some during personal characteristics and background controversy over whether the term relapse can be variables, in addition to immediate precipitants used to indicate any use following a period of absti- and coping responses, have also been proposed. Ac- nence, or whether it should be reserved for more cording to these models, individuals with charac- significant episodes of substance use that might teristics such as a family history of substance indicate a return to problematic use or in some abuse, concurrent psychiatric problems, and more cases dependence. At the present time, there is severe substance-use histories are at increased risk some consensus in the field that the term lapse for relapse during periods of abstinence. Risk for should be used for minor episodes of use following a relapse is further increased by factors such as major period of abstinence, whereas relapse should be life events, protracted life stressors, low social sup- used to connote major episodes of use, such as port, and low motivation for self-improvement. drinking five or more drinks on two or more consec- When individuals with these characteristics en- utive days. counter a high-risk situation, they are less likely to Among the addictions, rates of relapse are rela- be able to mount an effective coping response. tively high among individuals who achieve absti- Other models of relapse place much less empha- nence with or without formal treatment. For exam- sis on conscious, cognitive processes. For example, ple, up to 60 percent of alcoholics, heroin addicts, one classical conditioning model proposes that sud- and smokers relapse within three months of the end den urges to use, or cravings, are triggered when an of treatment. Although relapse episodes are com- individual encounters a situation or experience that mon, most substance abusers do experience sub- has been frequently paired with substance use in stantial reductions in the frequency and severity of the past. For example, a former substance abuser use for extended periods after treatment. Addic- might suddenly experience craving for cocaine tions are now thought to be chronic, relapsing dis- when he encounters someone with whom he used to orders in which afflicted individuals cycle through smoke cocaine. Another model postulates that re- periods of heavy use, treatment, abstinence or relapses are frequently governed by ingrained, auto- duced use, and relapse. matic processes that occur below the level of con- A number of models have been proposed to scious thought. This might explain why in some explain the relapse process. One of the more influ- cases, substance abusers appear to have very little ential and widely accepted of these is the cognitive- insight into the factors that led them to relapse. A RELIGION AND DRUG USE 955

third model is focused on the importance of WITH- BIBLIOGRAPHY DRAWAL symptoms in the onset of relapse. This last BROWNELL, K. D., ET AL. (1986). Understanding and model would seem to better account for relapses preventing relapse. American Psychologist, 41, 765- that occur within a few days of the onset of absti- 782. nence than relapses that occur after months of ab- CONNORS,G.J.ET AL. (1996). Conceptualizations of re- stinence. However, there is some evidence that in- lapse: A summary of psychological and psychobiolog- dividuals who have been abstinent for significant ical models. Addiction, 91, S5-S14. periods of time could have experiences that trigger DONOVAN, D. M. (1996). Assessment issues and domains the onset of withdrawal-like feelings through clas- in the prediction of relapse. Addiction, 91, S29-S36. sical conditioning processes described above. MCKAY, J. R. (1999). Studies of factors in relapse to alco- Although the models briefly described here hol, drug, and nicotine use: A critical review of meth- tend to focus on particular factors or mechanisms odologies and findings. Journal of Studies on Alcohol, that are hypothesized within each model to play 60, 566-576. important roles in relapse, it is widely believed JAMES R. MCKAY that the process of relapse is actually determined by a host of factors, including motivation, mood states, craving, and coping behaviors, as well as other cognitive, biological, and interpersonal fac- RELIGION AND DRUG USE Drug use tors. Moreover, individuals probably differ with and religion have been intertwined throughout his- regard to the relative importance of various factory, but the nature of this relationship has varied tors in the onset of their relapse episodes. It is over time and from place to place. Alcohol and other drugs have played important roles in the also possible that the processes which bring about religious rituals of numerous groups. For example, relapses that occur relatively quickly differ to among a number of native South American groups, some degree from those that lead to relapse after TOBACCO was considered sacred and was used in long periods of abstinence or nonproblematic use. religious ritual, including the consultation of spirits One of the problems in developing a valid and the initiation of religious leaders. Similarly, model of the relapse process is that it is very diffi- wine, representing the blood of Christ, has been cult to study. It is usually not possible to interview central in the Holy Communion observances of or observe substance abusers immediately prior to both Roman Catholic and some Protestant relapse, so researchers have often had to rely on churches. Considered divine by the Aztecs of an- accounts of events leading up to relapse gathered cient Mexico, the PEYOTE cactus (which contains a at some point after the episode to obtain informa- number of psychoactive substances, including the tion on relapse precipitants. Unfortunately, there psychedelic drug MESCALINE) is used today in the is considerable evidence that retrospective reports religious services of the contemporary Native such as these can be inaccurate or biased because American church (Goode, 1984). substance abusers are either unaware of what Although tobacco, ALCOHOL, peyote, and other brought on a relapse or their memory is distorted. drugs have been important in the religious obser- Recently, researchers studying NICOTINE relapse vances and practices of numerous groups, many have begun to use palm-sized, portable computers religious teachings have opposed either casual use to systematically record in near real time informa- or the abuse of psychoactive drugs—and some reli- tion about the mood states, cognitions, and situa- gious groups forbid any use of such drugs, for tions that smokers experience, and to link these religious purposes or otherwise. Early in America’s factors to the onset of smoking relapse, which are history, Protestant religious groups were especially also recorded on the computers. It is not clear prominent in the TEMPERANCE MOVEMENT. Many whether this new technology will work adequately of the ministers preached against the evils of with abusers of other substances, such as ALCO- drunkenness, and well-known Protestant leaders, HOL and COCAINE. Final determinations of the va- such as John Wesley, called for the prohibition of lidity of various models of relapse will likely have all alcoholic beverages (Cahalan, 1987). The Lat- to await the development of better technologies ter-day Saints’ (Mormons) leader Joseph Smith with which to study the process. prohibited the use of all common drugs, including 956 RELIGION AND DRUG USE alcohol, tobacco, and caffeine (no coffee or tea), as teenagers and young adults. Fourth, during this did other utopian groups founded during the Great portion of the life span, many changes, opportuni- Awakening of the early 1800s. Religious groups ties, and risks occur; thus, the structures and guide- and individuals were also active in America’s early lines provided by religious commitment may be (1860s–1880s) antismoking movement (U.S. De- especially important in helping young people resist partment of Health and Human Services, 1992). In the temptation to use and abuse drugs. Finally, contemporary American society, certain religious evidence that religious conversion is most likely to commitments continue to be a strong predictor of occur during adolescence (Spilka, 1991) makes either use or abstinence from drugs, whether licit or this period particularly appropriate for research on illicit (Cochran et al., 1988; Gorsuch, 1988; Payne the link between religion and drug use. et al., 1991). For example, Islam forbids alcohol and opium use but coffee, tea, tobacco, khat, and THE RELATIONSHIP BETWEEN various forms of marijuana were not prohibited, RELIGIOUS COMMITMENT AND because they came into the Islamic world after the DRUG USE prohibitions were laid down. Indulgence in any debilitating substance is, however, not considered Research investigating the relationship between proper or productive. Christianity, Judaism, and religious commitment and drug use consistently in- Buddhism may not prohibit specific drugs, but they dicates that those young people who are seriously and most other widespread, mainstream religious involved in religion are more likely to abstain from traditions also caution against indulgence in most drug use than those who are not; moreover, among substances. In our society, many who have in- users, religious youth are less likely than non- dulged have sought the help of ALCOHOLICS religious youth to use drugs heavily (Gorsuch, ANONYMOUS (AA) or NARCOTICS ANONYMOUS 1988; Lorch & Hughes, 1985; Payne et al., 1991). (NA)—both self-help groups founded on strong Examples from 1979, 1989, and 1999. spiritual underpinnings. Figure 1 shows how drug use was related to reli- This discussion is limited to recent conditions in gious commitment among high school seniors in the United States, focusing on potentially danger- 1979, 1989, and 1999. Individuals with the highest ous, abusive, and/or illicit patterns of drug use. religious commitment were defined as those who Since such drug use is widely disapproved by most usually attend services once a week or more often religious teachings and leaders, it is not surprising and who describe religion as being very important to find that those with strong religious commit- in their lives; individuals with low commitment are ments are less likely to be drug users or abusers. those who never attend services and rate religion as Moreover, research findings clearly show that reli- not important. Figure 1 clearly indicates that those gious involvement has been a protective factor, with low religious involvement were more likely helping some adolescents resist the drug epidemics than average to be frequent cigarette smokers, oc- of the 1970s and 80s. casional heavy drinkers, and users of MARIJUANA Because religion has been found to be a protec- and COCAINE; conversely, those highest in religious tive factor against drug use and dependence and commitment were much less likely to engage in any because our society is concerned with drug use of these behaviors. Other analyses have shown that among young people, much of the research linking similar relationships exist for other illicit drugs religion with drug use focuses on adolescents and (Bachman et al., 1986) and for other age groups young adults. This age range is particularly impor- (Cochran et al., 1988; Gorsuch, 1988). tant for several reasons. First, it is the period during Recent Trends in Drug Use and Religious which most addiction to NICOTINE begins; the ma- Commitment. Figure 1 presents data from three jority of people who make it through their teens as points in time, separated by ten-year intervals. It is nonsmokers do not take up the habit during their obvious in the illustration that between 1979 and twenties or later (Bachman et al., 1997). Second, 1989, the proportion of high school seniors using ADOLESCENCE and young adulthood is the period the illicit drugs marijuana and cocaine declined during which abusive alcohol consumption is most markedly; also during that decade, the proportion widespread. Third, recent EPIDEMICS in the use of reporting instances of heavy drinking declined ap- illicit drugs have been most pronounced among preciably, as did the proportion of frequent RELIGION AND DRUG USE 957

Part A. Daily Use of Half-Pack or More Cigarettes Part B. Binge Drinking (5 or More Drinks per Occasion) in Last Two Weeks 30 50 1979 1979 25 1989 40 1989 20 1999 1999 30

15 Percent 10 Percent 20 5 10

0 0 Low Med-Low Med-High High Low Med-Low Med-High High Religious Commitment Religious Commitment

Part C. Use of Marijuana in Past Thirty Days Part D. Use of Cocaine in Past Year

25 1979 1979 50 1989 20 1989 40 1999 15 1999

30 Percent

Percent 10 20 10 5

0 0 Low Med-LowMed-High High Low Med-Low Med-High High Religious Commitment Religious Commitment Figure 1 Drug use among high school seniors shown separately for four levels of religious commitment: 1979, 1989, and 1999. smokers. Between 1989 and 1999, the proportion counted for the declines in illicit drug use, factors of cigarette users and marijuana users rose some- such as the increasing levels of risk and the height- what; for year-to-year changes in substance use, ened disapproval associated with such behaviors see Johnston et al. (2000). For the present pur- (Bachman et al., 1988, 1990; Johnston, 1985; poses, the most important ﬁnding in Figure 1 is that Johnston et al., 2000). Moreover, Figure 2 shows religion was linked to drug use at all three times, that religious commitment—especially ratings of although the relationships appear a bit more dra- importance—actually rose slightly during the matic during periods of heavier use. 1990s, so it does not appear that the rise in use of Because high religious commitment is associated some drugs during the 1990s is attributable to any with low likelihood of drug use, it is reasonable to further drop in religiosity. ask whether any of the decline in illicit drug use Religion as a Protective Factor. The most during the 1980s could be attributed to a height- plausible interpretation of the relationship between ened religious commitment among young people religion and drug use during recent years, in our during that period. The answer is clearly negative, view, is that religion (or the lack thereof) was not as illustrated in Figure 2. The same annual surveys primarily responsible for either the increases or the that showed declines in drug use also indicated that subsequent decreases in illicit drug use. Rather, it religious commitment, rather than rising during the appears that those with the strongest religious com- 1980s, was actually declining among high school mitment were least susceptible to the various epi- seniors. It thus appears that other factors ac- demics in drug use. Figure 3 (adapted from Bach- 958 RELIGION AND DRUG USE

Trends in American Youth's Religiosity, 1976–1999 50

Non-Affiliation 12th Grade 45 Attendance (Weekly) 12th Grade Importance (Very) 12th Grade 40

Percentage 20

0 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Survey Year Figure 2 Trends in American youth’s religiosity: 1976–1999. man et al., 1990) provides one example in support emphasis placed on drug use (Lorch & Hughes, of that interpretation. The figure illustrates trends 1988). In particular, the more fundamentalist Prot- in cocaine use from 1976 through 1988, distin- estant denominations, as well as Latter-Day Saints guishing among the four different degrees of reli- (Mormons) and African American Muslims, rule out gious commitment. Cocaine use roughly doubled the use of alcohol and tobacco and disdain illicit between 1976 and 1979 among high school seniors drug use. Research examining differences in drug and began to decline sharply after 1986. But the use among young people finds that those who belong most important pattern in the figure, for the pres- to fundamentalist denominations are more likely to ent purposes, is that these historical trends in co- abstain from drug use than are youth who belong to caine use were much more pronounced among those with little or no religious commitment. Put more liberal denominations (Lorch & Hughes, another way, it seems that strong religious commit- 1985). Analyses of the data on high school seniors ment operated as a kind of protective factor, shel- (Wallace & Forman, 1998) corroborate the findings tering many youths from the waves of drug use of earlier research; the number of young people sweeping the nation. strongly committed to fundamentalist denomina- Denominational Differences. There are im- tions (e.g., Baptists) who use drugs is much lower portant differences among religious groups in the than average and lower than the percentages for RELIGION AND DRUG USE 959

2 Truancy Index:

30-65 (high)

25 20

Mean Annual Cocaine Use (1-7 Scale) Mean Annual 15 10 (low) 1 '76 '80 '84 '88 Year of Survey Figure 3 Trends in annual cocaine use shown separately for five levels of truancy, high school seniors: 1976–1988. those strongly committed to other religious smoke have become dependent on nicotine and find traditions. it very difficult to quit. Changes During Young Adulthood. Panel surveys that followed high school seniors up to POSSIBLE CAUSAL PROCESSES fourteen years after graduation revealed that sub- Since religious commitment is negatively related stance use often increases in response to new free- to drug use, it becomes important to understand doms such as leaving high school and moving out of the possible causal processes underlying that rela- parents’ homes, whereas use often decreases in re- tionship. Wallace and Williams’ socialization influ- sponse to new responsibilities such as marriage, ence model (1997) specifies a number of possible pregnancy, and parenthood (Bachman et al., mechanisms through which religious commitment 1997). Additional analyses of these data reveal that might operate to influence adolescent drug use. The religion continues to be strongly related to various model postulates that health-compromising behav- forms of drug use during the late teens, twenties, iors like drug use are the result of a dynamic social- and early thirties. These analyses reveal that reli- ization process that begins in childhood and ex- gious attendance and importance change rather tends throughout the course of life. According to little for most individuals, but when changes in the model, the family is the primary and first social- religiosity occur, there tend to be corresponding ization influence, and a continuing source of social- changes in substance use. Specifically, increases in ization into the norms and values of the larger religious commitment are correlated with declines society. The model hypothesizes that religion, peer in the use of alcohol and illicit drugs. Smoking networks, and other contexts in which young peo- behavior, on the other hand, is linked with religios- ple find themselves (e.g., schools) operate as key ity during high school and thus also during young secondary socialization influences that impact drug adulthood. However, after high school, smoking use, primarily indirectly, through their influence on behavior is relatively little affected by changes in key socialization mechanisms, including social con- religiosity—presumably because by the time of trol, social support, values, and individual and young adulthood, most individuals who continue to group identity. Below, we describe some of the 960 RELIGION AND DRUG USE ways in which religion, parents, peers, and other drug use, the norms of the peer group are especially potential causes might overlap to influence adoles- important as predictors of whether a particular cent drug use. The socialization influence model teenager will start using drugs (Jessor & Jessor, further suggests that key aspects of adolescent reli- 1977). giosity, particularly denominational affiliation and Overlaps with Other Causes. Religious com- religious attendance, are often under the control of mitment among young people is correlated with a parents and reflect the types of doctrinal beliefs, number of other factors known to relate to drug teachings, and adult and peer models to which par- use. In particular, students who achieve good ents want their children exposed. grades, who plan to go to college, and who are not Content of Religious Teaching. One possible truant are also less likely to use drugs, as well as causal process seems obvious: Most religious tradi- more likely to display high levels of religious com- tions teach followers to avoid the abuse of drugs. mitment. These various factors are closely interre- Restrictions vary, of course, from one tradition to lated in a common syndrome (Dryfoos, 1990; another, and the greater emphasis on prohibition in Jessor & Jessor, 1977), and thus it is difficult to fundamentalist denominations seems the most disentangle causal processes. Indeed, it could be likely explanation for the lower levels of use among argued that religious commitment is probably one adherents. But even in traditions that do not explic- of the root causes, contributing to both educational itly or completely ban drug use, there is still much success and the avoidance of drug use. Analyses of teaching ranging from respect for one’s own body possible multiple causes of drug use (or abstention) to family responsibilities to broader social responsi- have shown that religious commitment overlaps bilities, all arguing against the abuse of drugs. Be- with other predictors, but only partially. In other cause all drugs, including cigarettes and alcohol, words, although religious commitment may be part are illicit for minors, young people who are strongly of a larger syndrome, it also appears to have some committed to religion may abstain from drug use simply in obedience to the laws of the nation; but unique (i.e., nonoverlapping) impact on drug use. even more important, they are likely to act in obedience to what they perceive to be God’s laws. CONCLUSION Parental Examples and Precepts. In addi- The relationship between religion and drug use tion to the direct teachings associated with attend- among young people is not completely straightfor- ance at religious services, young people raised in ward. On the one hand, a considerable amount of religious traditions are likely to be exposed to par- research indicates that young people who are ents and other relatives who follow such teachings. strongly committed to religion are less likely than Thus, part of the explanation for less drug use their uncommitted counterparts to use drugs. On among religiously involved young people may be the other hand, data presented here and elsewhere that their families reinforce the religious structures against use and abuse. A further factor may simply suggest that religion has had relatively little impact be availability; religious parents who do not drink, on recent national declines in drug use among smoke, or use drugs will not have these substances young people. Further examination of this relation- in their homes, thus reducing the opportunity for ship reveals that America’s drug epidemic occurred young people to experiment with them. primarily among those not affected by religion; Peer Group Factors. The dynamics operating highly religious youth were relatively immune to within the family probably have their parallel in the plague that infected a significant portion of the broader social contacts. That is, those who are nation’s youth. Accordingly, we conclude that reli- strongly committed to religion probably associate gious commitment has been, and continues to be, with others holding similar views. Thus, the an effective deterrent to the use and abuse of licit strongly religious are less likely to belong to peer and illicit drugs. groups that encourage experimentation with ciga- This work was supported by Research Grant No. rettes, alcohol, and other drugs and more likely to 3 R01 DA 01411 from the National Institute on participate in peer networks and activities that do Drug Abuse. We thank Dawn Bare for her contri- not involve drugs. Given the strong relationship be- bution to data analysis and figure preparation and tween drug use by peers and an adolescent’s own Tanya Hart for her editorial assistance. REMOVE INTOXICATED DRIVERS (RIDUSA, INC.) 961

(SEE ALSO: Ethnic Issues and Cultural Relevance in Etiology of drug abuse: Implications for prevention. Treatment; Jews, Drug and Alcohol Use Among; Washington, DC: U.S. Government Printing Office. Prevention Movement; Vulnerability: An Overview) JOHNSTON, L. D., O’MALLEY, P. M., & BACHMAN,J.G. (2000). National survey results on drug use from the Monitoring the Future study, 1975-1999. Volume I: BIBLIOGRAPHY Secondary school students. Volume II: College stu- BACHMAN, J. G., WADSWORTH, K. N., O’MALLEY, P. M., dents and young adults. Rockville, MD: National In- JOHNSTON,L.D.,&SCHULENBERG, J. (1997). Smok- stitute on Drug Abuse. ing, drinking and drug use in young adulthood: The LORCH, B. R., & HUGHES, R. H. (1988). Church, youth, impacts of new freedoms and new responsibilities. alcohol, and drug education programs and youth sub- Mahwah, NJ: Lawrence Erlbaum Associates. stance abuse. Journal of Alcohol and Drug Education, BACHMAN, J. G., JOHNSTON, L. D., & O’MALLEY,P.M. 33(2), 14–26. (1990). Explaining the recent decline in cocaine use LORCH, B. R., & HUGHES, R. H. (1985). Religion and among young adults: Further evidence that perceived youth substance use. Journal of Religion and Health, risks and disapproval lead to reduced drug use. Jour- 24(3), 197–208. nal of Health and Social Behavior, 31(2), 173–184. PAYNE, I. R., BERGIN, A. E., BIELEMA, K. A., & JENKINS, P. H. (1991). Review of religion and mental health: BACHMAN, J. G., JOHNSTON, L. D., O’MALLEY, P. M., & Prevention and the enhancement of psychosocial HUMPHREY, R. H. (1988). Explaining the recent de- functioning. Prevention in Human Services, 9(2), cline in marijuana use: Differentiating the effects of 11-40. perceived risks, disapproval, and general lifestyle fac- SPILKA, B. (1991). Religion and adolescence. In R. M. tors. Journal of Health and Social Behavior, 29,92– LERNER ET AL. (Eds.), Encyclopedia of adolescence. 112. New York: Garland. BACHMAN, J. G., O’MALLEY, P. M., & JOHNSTON,L.D. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. (1986). Change and consistency in the correlates of (1992). Smoking and health in the Americas. Atlanta: drug use among high school seniors: 1975-1986 Public Health Service, Centers for Disease Control, (Monitoring the Future Occasional Paper No. 21.) National Center for Chronic Disease Prevention and Ann Arbor: University of Michigan, Institute for So- Health Promotion, Office of Smoking and Health. cial Research. WALLACE, J. M., Jr., & FORMAN, T. A. (1998). Religion’s BOCK, E. W., COCHRAN,J.K.,&BEEGHLEY, L. (1987). role in promoting health and reducing risk among Moral messages: The relative influence of denomina- American youth. Health Education and Behavior tion on the religiosity-alcohol relationship. Sociologi- 25(6), 721–41. cal Quarterly, 28(1), 89–103. WALLACE, J. M., Jr., & WILLIAMS, D. (1997). Religion CALAHAN, D. (1987). Understanding America’s drinking and adolescent health-compromising behavior. In J. problem. San Francisco: Jossey-Bass. SCHULENBERG,J.MAGGS,K.HURRELMANN (Eds.), COCHRAN, J. K., BEEGHLEY, L., & BOCK, E. W. (1988). Health risks and developmental transitions during Religiosity and alcohol behavior: An exploration of adolescence. New York: Cambridge University Press. reference group theory. Sociological Forum, 3(2), JERALD G. BACHMAN 256–276. JOHN M. WALLACE,JR. DRYFOOS, J. G. (1990). Adolescents at risk: Prevalence and prevention. New York: Oxford University Press. GOODE, E. (1984). Drugs in American society, 2nd ed. REMOVE INTOXICATED DRIVERS New York: Knopf. (RIDUSA, INC.) Founded in 1978, this volun- GORSUCH, R. L. (1988). Psychology of religion. Annual teer grass-roots organization (P.O. Box 520, Sche- Review of Psychology, 39, 201–221. nectady, NY 12301; 518–372–0034) is devoted to JESSOR, R., & JESSOR, S. L. (1977). Problem behavior efforts to deter impaired driving, help victims seek and psychosocial development: A longitudinal study justice and restitution, close loopholes in DWI of youth. New York: Academic Press. (driving while impaired) laws, and educate the JOHNSTON, L. D. (1985). The etiology and prevention of public on the scope of impaired-driving tragedies. substance use: What can we learn from recent histori- RID activists have played a key role in the passage cal changes? In C. L. JONES &R.J.BATTJES (Eds.) of reforms of the impaired-driving laws in many 962 REPEAL OF PROHIBITION states, enabled passage of more than 500 anti-DWI behavioral psychologists and psychopharmaco- laws, and monitored more than 15,000 court cases. logists explore the interactions between drug ac- RID’s victim-support activities, which are free, tions and behavior in laboratory settings. The sec- include providing long-term emotional support to tion begins with an overview article, Aims, victims of drunk-driving crashes and to their fami- Description, and Goals. The article Developing lies; counseling victims and accompanying them Medications to Treat Substance Abuse and Depen- throughout all phases of criminal prosecution of the dence ties basic research directly to clinical appli- offender; assisting victims in obtaining compensa- cations. The articles on Drugs as Discriminitive tion; and referring victims and their families to Stimuli; Measuring Effects of Drugs on Behavior; appropriate supportive agencies. Court monitoring Measuring Effects of Drugs on Mood; and Motiva- and research activities include monitoring the ef- tion describe these general research techniques and forts of police, prosecutors, magistrates, and judges concepts and their applicability to understanding in drunk-driving cases through research and analy- drug abuses. sis of local court records, and reporting these find- Research in the field of drug dependence, how- ings to the public. RID’s public awareness and edu- ever, is much broader and more diverse than the cation activities are extensive. Members organize topics included in this section. In fact, research is public meetings; present educational talks to com- conducted on most of the topics contained in this munity and religious organizations; participate in encyclopedia—from epidemiological studies to forums, exhibits, and media events; supplement new methods for detecting drug smuggling; from high school driver-education classes; and support herbicides that can target specific plant sources of SADD (STUDENTS AGAINST DRIVING DRUNK) and illicit drugs to how to target prevention messages to other similar student groups. They study and re- subgroups within the population; from how certain port on alcohol-related vehicle and traffic laws; drugs produce their toxic effects to developing new support concepts such as designated-driver and al- drugs to reduce drug craving or prevent relapse; cohol-server education, and promote SNAP (a Sane from how the interactions of environment and ge- National Alcohol Policy), which advocates raising netics make certain individuals more vulnerable to taxes on alcohol, curbing campus beer promotions, drug use to the relative effectiveness of different and airing public-service advertising to counter all treatment programs. Many of these research issues broadcast alcohol commercials. are touched upon in such diverse articles as those RID is organized into autonomous chapters, on controlling illicit drug supply; on TREATMENT; with more than 150 chapters in at least forty-one or PREVENTION; and on VULNERABILITY AS A CAUSE states in the United States and a national group in OF SUBSTANCE ABUSE. France. Financial support comes from member Clinical, behavioral, epidemiological, and basic dues, government and corporate grants, charitable research is carried out primarily by researchers at contributions, and memorial gifts. Information on universities, government research centers, and re- how to organize a RID chapter is available from the search institutes. It is funded both publicly and national office in Schenectady, New York. privately. The work of a representative few of these centers is described elsewhere in the encyclopedia (SEE ALSO: Accidents and Injuries from Alcohol, (see Addiction Research Foundation (Canada); Ad- Dramshop Liability Laws; Drunk Driving; Mothers diction Research Unit (U.K.); Center on Addiction Against Drunk Driving) and Substance Abuse (CASA); Rutgers Center of Alcohol Studies; U.S. Government/U.S. Govern- FAITH K. JAFFE ment Agencies (SAMHSA, NIAAA, NIDA, CSAP, CSAT). In 1992, worldwide, there were more than eighty research centers devoted to problems of REPEAL OF PROHIBITION See drugs and alcohol. Fifty-eight of the centers were in Prohibition of Alcohol the United States; thirteen were in Europe and the U.K.; the others were in Central and South Amer- ica, Asia, Australia, and New Zealand. RESEARCH This section is devoted primar- For more information on research, see also Im- ily to detailed explanations of the ways in which aging Techniques: Visualizing the Living Brain; RESEARCH: Aims, Description, and Goals 963

Pain: Behavioral Methods for Measuring the Anal- movement of molecules to the behavior of entire gesic Effects of Drugs; Research, Animal Models. human cultures. Chemists determine the physical structure of abused substances, and then molecular biologists try to determine exactly how they inter- Aims, Description, and Goals In a Chi- act with the subcellular structures of the human nese book on pharmacy, which dates to 2732 B.C., body. Geneticists try to determine what compo- references are found to the properties of MARIJUANA nents, if any, of substance abuse are genetically (a type of Old World HEMP, Cannabis sativa of the linked. Pharmacologists determine how the body mulberry family). In an Egyptian papyrus from breaks down abused substances and sends them to about 1550 B.C., there is a description of the effects different sites for storage or elimination. Neurosci- of OPIUM (a product of the opium poppy, Papaver entists examine the effects of drugs and alcohol on somniferum). In almost every culture, the uses of the cells and larger anatomical structures of the ALCOHOL are documented in both oral and written brain and other parts of the nervous system. Since tradition, often going back into antiquity—the Bi- these structures control our thoughts, emotions, ble, for example, mentions both the use and abuse learning, and perception, psychologists and behav- of wine. Although people have made observations ioral pharmacologists study the drugs’ effects on on PSYCHOACTIVE substances for thousands of their functions. Cardiologists and liver and pulmo- years, much remains to be learned about both alco- nary specialists study the responses of heart, liver, hol and drugs of abuse; much research remains to and lungs to drugs and alcohol. Immunologists ex- be done before these substances and their effects amine the consequences of substance abuse for the can be fully understood. immune system, a study made critical by the AIDS epidemic. The conclusions reached through these basic scientific inquiries guide clinicians in devel- WHAT WE NEED TO KNOW oping effective treatment programs. Most substance-abuse research carried out today In considering drug abuse, people have long is a consequence of public health and social con- wondered why so many plants contain substances cerns. With millions of people using and abusing that have such profound effects on the human many different substances, and because of the close brain and mind. Surely people were not equipped association between AIDS and drug abuse, it is by nature with special places on their nerve cells imperative to know just how dangerous—or not (called RECEPTORS) for substances of abuse—on dangerous—any given drug is to public health and the off chance that they would eventually smoke safety. For economic as well as medical reasons, it marijuana or take COCAINE or HEROIN. The discov- is essential to find the most effective ways to use our ery in the late 1960s that animals would work to health resources for preventing and treating sub- obtain injections or drinks of the same drugs that stance abuse. So many questions still exist that no people abuse was an important scientific observa- one scientific discipline can answer them all. The tion; it contributed to the hypothesis that there answers must be found through studies in basic must be a biological basis for substance abuse. chemistry, molecular biology, genetics, pharmacol- These observations and this reasoning led scientists ogy, neuroscience, biomedicine, physiology, behav- to look for substances produced by people’s own ior, epidemiology, psychology, economics, social bodies (endogenous substances) that behave chem- policy, and even international relations. ically and physiologically like those people put into From a social standpoint, the first question for themselves from the outside (exogenous sub- research must be: How extensive is the problem? stances)—like alcohol, NICOTINE, marijuana, co- Surveys and other indicators of drug and alcohol caine, and other drugs of abuse. When receptors for usage are the tools used by epidemiologists to de- endogenous substances were discovered—first for termine the extent and nature of the problem, or to the OPIATES in the 1970s and only recently for PCP, find out how many people are abusing exactly cocaine, marijuana, and LSD—their existence which drugs, how often, and where. As the dimen- helped establish the biological basis for drug abuse. sions of the problem are defined, basic scientists So did the discovery of a genetic component for begin their work, trying to discover the causes and certain types of ALCOHOLISM. These discoveries by effects of substance abuse at every level, from the no means negate the extensive behavioral and so- 964 RESEARCH: Aims, Description, and Goals cial components of substance abuse, but they do not always orderly. Critical observations by clini- suggest a new weapon in dealing with the prob- cians frequently provide basic researchers with im- lem—that is, the possibility of using medication, or portant insights, which guide the research into new a biological therapy, as an adjunct to psychosocial channels. Observations in one science often lead to therapies. Asserting a biological basis for substance breakthroughs in other areas. abuse also removes some of the social stigma attached to drug and alcohol addiction. Since drug METHODS dependence is a disorder with strong biological components, society begins to understand that it is The range of methods employed by scientists not merely the result of weak moral fiber. studying substance abuse is as wide as the range of Armed with information that was derived from methods in all the biological and social sciences. basic research, clinical researchers in hospitals and One important method is the use of animal models clinics test and compare treatment modalities, of behavior to answer many of the questions raised looking for the best balance of pharmacological by drug and alcohol use. Animal models are used in and psychosocial methods for reclaiming shattered biomedical research in virtually every field, but the lives. Finding the right approach for each type of discovery that animals will, for the most part, self- patient is an important goal of treatment research, administer alcohol and the same drugs of abuse since patients frequently have a number of physical that humans do, meant that there was a great po- and mental problems besides substance abuse. The tential for behavioral research uncontaminated by development of new medications to assist in the many of the difficult-to-control social components treatment process is an exciting and complex new of human research. The results of animal studies frontier in substance-abuse research. have been verified repeatedly in human research The best way to prevent the health and social and in clinical observation, thus validating this ani- problems that are associated with substance abuse mal model of human drug-seeking behavior. has always been a significant research question. Research Personnel. Drug- and alcohol- Insights gained from psychological and social re- abuse research is conducted by many different search enable us to design effective prevention pro- types of qualified professionals, but mostly by med- grams targeted toward specific populations that are ical researchers (MDs) and people with advanced particularly vulnerable to substance abuse for both degrees (PhDs) in the previously mentioned sci- biomedical and social reasons. Knowing the conse- ences. They work with animals and with patients in quences of substance abuse often helps researchers university and federally funded laboratories, as to formulate prevention messages. For example, the well as in privately funded research facilities, in identification of the FETAL ALCOHOL SYNDROME offices, and in clinical treatment centers. Other sites (FAS), a pattern of birth defects among children of include hospitals, clinics, and sometimes schools, mothers who drank heavily during pregnancy, was the streets, and even advertising agencies when a major research contribution to the prevention of prevention research is under way. alcohol abuse. Drug-abuse-prevention research has assumed a new urgency with the realization, FUNDING brought about by epidemiologists and others, that the AIDS virus is blood-borne—spread by sexual Who pays for substance-abuse research has al- contact and by drug abusers who share contami- ways been an important issue. In the late 1980s and nated syringes and needles. HIV-positive drug early 1990s, most of the drug- and alcohol-abuse users then spread the disease through unprotected research in the world was supported by the U.S. sexual intercourse. Public education about drug government. One of the federally funded National abuse and AIDS must use the most powerful and Institutes of Health—the NATIONAL INSTITUTE ON carefully targeted means of reaching the popula- DRUG ABUSE (NIDA)—funds over 88 percent of tions at greatest risk for either disease, and these drug-abuse research conducted in the United States means can be determined only by the most careful and abroad. In 1992, this amounted to over 362 social research and evaluation methodologies. million dollars, which supported NIDA’s own in- Substance-abuse research is no different from tramural research at the Addiction Research Center any other sort of scientific endeavor: The process is and the research done in universities under grants RESEARCH: Clinical Research 965

awarded by the institute. NIDA’s sister institute, JAFFE, J. H. Drug addiction and drug abuse. (1990). In the NATIONAL INSTITUTE ON ALCOHOL ABUSE AND A. G. Gilman et al. (Eds.), Goodman and Gilman’s ALCOHOLISM (NIAAA), plays a parallel role in the pharmacological basis of therapeutics, 8th ed. funding alcohol-abuse research. In 1992, it funded New York: Pergamon. 175 million dollars in alcohol-research grants. CHRISTINE R. HARTEL Many other U.S. government agencies also have important roles in sponsoring and conducting substance-abuse research. For the most part, state and Clinical Research In the process of devel- local governments do not sponsor substance-abuse oping new drugs, pharmaceutical companies must research, although they do much of the distribution perform rigorous studies in the laboratory, in ani- of funds for treatment and prevention programs. mals, and then, if the drug looks promising, in Other countries, most notably Canada, sponsor humans. Carefully designed research into the safety basic clinical and epidemiological substance-abuse and effectiveness of a drug in humans is called research within their own universities and labora- CLINICAL RESEARCH (or CLINICAL TRIALS). Research tories, but none does so on a scale that is compara- resulting from new surgical techniques, medical ble to that of the United States. Private foundations devices, and other medical treatments also fall un- and research institutions like the Salk Institute for der this heading. Biological Studies, Rockefeller University, and the To conduct research in humans, approval must Scripps Clinic and Research Foundation use their be obtained from the Food and Drug Administra- own funds, as well as federal grant support, to pay tion (FDA). The research sponsors (usually the for their research endeavors. Pharmaceutical com- pharmaceutical company) submit a detailed appli- panies also support some substance-abuse re- cation termed an Investigational New Drug Appli- search—mostly clinical work related to medica- cation that summarizes the drug characteristics, tions that might be used as part of treatment manufacturing process, and results of any labora- programs for drug and alcohol abuse. Again, much tory and animal studies. In addition, this applica- of this work is sponsored, in part, by the U.S. tion provides detailed information regarding pro- government. posed studies in humans, including the research protocol, data collection documents, and informed (SEE ALSO: National Household Survey; Substance consent form. If the drug is proven to be safe and Abuse and HIV/AIDS; Research, Animal Model; effective, the sponsors can submit a voluminous U.S. Government/U.S. Government Agencies) application called a New Drug Application to the Food and Drug Administration. This application BIBLIOGRAPHY contains the material in the Investigational New Drug Application as well as the data, analyses, and ALCOHOL AND HEALTH. (1990). Seventh Special Report to conclusions of all of the clinical trials conducted. the U.S. Congress. DHHS Publication no. (ADM) Clinical trials of drugs or medical devices prog- 90-1656. Washington, DC: U.S. Government Printing ress through four phases. Phase I studies are con- Office. ducted on healthy volunteers to assess the safety of BARINAGA, M. (1992). Pot, heroin unlock new areas for the drug or device. Phase II studies are conducted neuroscience. Science, 258, 1882–1884. on a relatively small group of patients with the COOPER, J. R., BLOOM, F. E., & ROTH, R. H. (1986). The target disease to assess effectiveness as well as biochemical basis of pharmacology. New York: Ox- safety. Phase III studies are conducted on a large ford University Press. group of patients with the target disease to confirm DRUG ABUSE AND DRUG ABUSE RESEARCH III. (1991). Third effectiveness, observe side effects, and to compare Triennial Report to Congress. DHHS Publication no. the test treatment to the standard treatment. Phase (ADM) 91-1704. Washington, DC: U.S. Government IV studies are performed for a variety of reasons Printing Office. after the drug or device has been on the market. GERSHON, E. S., & RIEDER, R. D. (1992). Major disorders Reasons for conducting phase IV studies include: to of mind and brain. Scientific American, 267(3), 126– test the treatment in different populations (e.g., in 133. children or the elderly), to assess the effects of long- 966 RESEARCH: Clinical Research term use of the treatment, or to use the treatment are not strong enough (not statistically significant) on a different target disease. to prove that the test treatment is effective. The sample size is based upon, among other things, the STUDY DESIGN number of treatment and control groups in the study and an estimation of the expected differences Study design is a crucial determinant of the between these groups. strength, validity, and subsequent usefulness of The study design is contained within the study clinical research results. Study design is the meth- protocol, which is a detailed document that outlines odology used to conduct the clinical research. Many every aspect of the study. The protocol is essentially different types of clinical research studies exist. The a set of rules that the investigator(s) must follow. It strength of the data depends upon the conditions covers such things as who may be entered into the used during the conduct of the trial. Also, these study, how to collect and record data, and how to conditions help to eliminate bias by the investiga- record and report adverse reactions. Violation of tor, patient, or others who are involved in the col- any of the rules set forth in the protocol can dis- lection and analysis of the data. The most impor- qualify an investigator, a patient, or even the entire tant conditions are blinding, randomization, and study. controlling. The randomized, controlled, double Although the randomized, controlled, single and blind study is considered to be the clinical research double blind studies are very common designs, ideal. there are other study designs which may be used. Blinding refers to the process in which the pa- The sponsor may initially conduct dose-finding tient does not know whether he or she is receiving studies in order to find the optimal dose of a test the test treatment or a placebo treatment. In the drug to treat the target disease. In the cross-over single blind design, the patient does not know design, patients receive both treatments being com- which treatment he or she is receiving. The investi- pared (or treatment and a placebo) which factors gator knows, however, and this may lead to bias. out inter-individual variability. Each patient would Ideally, studies should be double blind, a condition receive one treatment for a designated time period, in which neither the patient nor any of the other their disease state would be evaluated, and then people who are actively involved in the study have they would switch to the other treatment for a des- knowledge of the treatment. ignated time period. Other, more complex study Randomization refers to the process in which the designs are also employed. However, with increas- patients are randomly assigned to the various treating complexity comes increasing difficulties in data ments. This insures that the test treatment and analysis, interpretation, and validity. controls are allocated to the patient by chance, and not the choice of the investigator. Randomization ETHICAL CONSIDERATIONS eliminates the possibility that an investigator could sway study results. Federal regulations insure that the rights of sub- Clinical research studies can be either controlled jects in a clinical trial are protected. Each clinical or uncontrolled. Controls can be either the stan- trial must be approved and monitored by a com- dard treatment for the target disease (active con- mittee known as an Institutional Review Board, trolled ) or a placebo (vehicle controlled ). Many which has medical, scientific, and non-scientific diseases have a natural tendency to wax and wane members. Institutional Review Boards review and so study results can be misleading without a control approve trial documents such as the protocol and group to serve as a comparator to the treatment informed consent form as well as the advertising group. Because controlled studies are a more reli- materials needed to attract subjects. The purpose of able indicator of a treatment’s effectiveness, uncon- the Institutional Review Board is to protect the trolled studies are considered as preliminary or rights, safety, and well-being of the study subjects. suggestive, or they may be disregarded altogether. The Food and Drug Administration requires Another important component of study design is that all participants in a clinical trial be informed of the determination of the sample size, or number of the details of the study. This process is called inpatients to include in the study. A sample size that formed consent. Informed consent usually involves is too small will yield a study in which the results a lengthy document (informed consent form) that RESEARCH: Developing Medications to Treat Substance Abuse and Dependence 967 describes key facts about the study including: the associated with drug use; they may also help ensure purpose of the research, what the goals are, what compliance in taking the medication that is pre- procedures will be done, what the possible risks scribed. are, what the possible benefits are, and what other treatments are available for the target disease. In PERPETUATION OF DRUG ABUSE: addition, the informed consent form stresses that EUPHORIA AND WITHDRAWAL the subject can leave the study at any time. An important component of the informed consent pro- Many people who are drug- or alcohol-depen- cess is that the subject has the opportunity to ask dent want to stop their habit, but often they have a questions regarding the study and/or the consent difficult time doing so. There are at least two rea- form. sons for this difficulty. First, the drugs produce pleasant or euphoric feelings that the user wants to experience again and again. Second, unpleasant CONCLUSION effects can occur when the drug use is stopped. Clinical research plays an invaluable role in the The latter effect, commonly known as WITH- ongoing process of finding effective and safe treat- DRAWAL, has been shown after prolonged use of ments for diseases. The information obtained by many drugs, including alcohol, OPIATES (such as clinical trials provides physicians with the neces- HEROIN), SEDATIVE HYPNOTICS, and anxiety-re- sary information to make informed choices in the ducing drugs. Other drugs, such as COCAINE and treatment of their patients. Clinical studies are key even CAFFEINE (COFFEE and COLA drinks) and in identifying the optimal doses of a new drug and NICOTINE (cigarettes), are also believed to be asso- also in providing information regarding the occur- ciated with withdrawal effects after prolonged use. rence and incidence of adverse reactions. However, These unpleasant withdrawal effects are alleviated clinical research is limited by sample size. Even by further drug use. Thus drugs are used and studies comprised of thousands of subjects will fail abused because they produce immediate pleasant to pick up extremely rare, possibly serious adverse effects and because the drug reduces the discom- reactions that materialize during clinical use. fort of withdrawal. The symptoms of withdrawal are fairly specific BIBLIOGRAPHY for each drug and include physiological effects and psychological effects. For example, alcohol with- BOWLING, A. (1997). Research methods in health: inves- drawal can be associated with shaking or head- tigating health and health services. Buckingham: aches, and opiate withdrawal with anxiety, sweat- Open University Press. ing, and increases in blood pressure, among other ‘‘What is a clinical trial?’’ National Institutes of Allergy effects. Withdrawal from cocaine may cause de- and Infectious Disease & National Institutes of Health & cited 4 September 2000 & http:// pression or sadness, withdrawal from caffeine is www.niaid.nih.gov/clintrials/clinictrial.htm. associated with headaches, and withdrawal from nicotine often produces irritability. All drug with- BELINDA ROWLAND drawals are also associated with a strong craving to use more drugs. Much work has been done to document the withdrawal effects from alcohol, opiates, Developing Medications to Treat Sub- BENZODIAZEPINES, and tobacco; however, docu- stance Abuse and Dependence Dependence mentation of withdrawal from cocaine or other on drugs, ALCOHOL,orTOBACCO is difficult to treat, stimulant drugs has only recently begun to be and practitioners have tried many approaches in examined. their attempts to arrive at successful treatments. One approach is to develop medications, or phar- NEURAL CHANGES WITH CHRONIC macological treatments. This approach is most ef- DRUG USE fective when the medication is given along with behavioral treatments. These behavioral treat- Both withdrawal and the pleasant or euphoric ments help the individual cope with the underlying effects from drug use occur, in part, as a result of etiology of his or her drug use and the problems the drug’s action on the brain. The immediate or 968 RESEARCH: Developing Medications to Treat Substance Abuse and Dependence acute effects of most drugs of abuse affect areas of RESEARCH ON DRUG EFFECTS the brain that have been associated with ‘‘reward’’ Many of these acute and chronic effects of drugs or pleasure. These drugs stimulate areas normally on the brain have been investigated in animal re- aroused by natural pleasures such as eating or sex- search, which allows greater control over the re- ual activity. Long-term, or chronic, drug use alters search, including manipulations of drug exposure. these and other brain areas. Some brain areas will A number of animal models are used to assess drug develop TOLERANCE to the drug effects, so that preferences, and, since most drugs that humans greater and greater amounts are needed to achieve abuse are also preferred by animals, these models the original effects of the drug. Some examples of are useful for understanding human drug abuse. drug effects that develop tolerance are the ANALGE- Moreover, animal research allows scientists to SIC or painkilling effect of opiates and the euphoria- study directly the various areas of the brain that are or pleasure-producing effect of most drugs of involved in drug use. In addition, recent technolog- abuse, which are probably related to their abuse ical advancements on noninvasive IMAGING have potential. allowed scientists to took at pictures of the brains of Because some brain areas may also become sen- humans while they are being administered drugs or sitized, an original drug effect will either require a while they are withdrawing from drugs. This hu- lesser amount of the drug to elicit the effect when man work has also enhanced our knowledge of the drug effects on the brain as well as validated the the drug is used chronically or the effect becomes information gained from animal research. greater with chronic use. This phenomenon has Another useful line of research in assessing the been studied most extensively in cocaine use. Co- effects of drugs involves human laboratory studies. caine is associated with behavioral sensitization of In one type of study, research volunteers who have motor activity in animals and paranoia (extreme had experience with the abused drugs are given a delusional fear) in humans. There are physiological specific drug (e.g., morphine), and various psycho- effects that develop tolerance or sensitization as logical and physiological measurements are ob- well. For example, the chronic use of cocaine will tained. The psychological measurements can in- sensitize some brain areas so that seizures are more clude reports from the subject on the effects of the easily induced. Other health risks of drug use will drug as well as more sophisticated behavioral mea- be addressed below. sures that tell the experimenter how much the drug In addition to these more direct acute and chron- is preferred. Another type of human laboratory ic drug effects, another phenomenon occurs with study is to study the effects of drug withdrawal. For long-term drug use. This phenomenon is the condi- opiates, withdrawal can be precipitated by an opi- tioned drug effect, in which the environmental or ate ANTAGONIST drug (NALTREXONE), and with- internal (mood states) cues commonly presented drawal signs and symptoms are measured. For with drug use become conditioned or psychologi- other drugs (such as cocaine), withdrawal is more cally associated with drug use. For example, when difficult to measure because little is known about their withdrawal syndromes. angry, a drug addict may buy or use drugs in a Some of the information that scientists have certain place with certain people. After frequently learned from such studies includes delineating spe- taking drugs under similar conditions, the individ- cific brain areas as well as the NEUROTRANSMITTERS ual can experience a strong craving or even with- (the chemicals released by the brain cells) involved drawal when in the environment in which he or she in drug use and withdrawal. Thus, when specific has taken drugs or feels angry. When the individual neurotransmitters become identified as playing an tries to stop using drugs, exposure to these condi- important role in drug use or withdrawal, scientists tioned cues can often lead to relapse because the can administer experimental drugs that act on craving and withdrawal effects are so powerful. these neurotransmitters to see if the animals will Very little research has been done on the neural alter their drug preference or show less severe with- bases of these conditioned effects; thus it is not drawal signs. Researchers can also give these exper- known whether these effects are mediated by simi- imental drugs to the human research volunteers to lar or different neural mechanisms. see if the medication alters the subject’s perception RESEARCH: Developing Medications to Treat Substance Abuse and Dependence 969 of or behavior toward the abused drug or if it transmitters that mediate the drug or alcohol alleviates withdrawal symptoms. If the results from effects. These new compounds are then tested in these animal and human laboratory studies are animals to see if they produce therapeutic effects. promising, then these agents can be tested on treat- These effects include having a low potential for ment-seeking, drug-dependent individuals in clini- being another drug of abuse and attenuating the cal trials. This latter type of research is more time- effects of the abused drug under study, preferably consuming and expensive than the laboratory stud- in a way that would lead to decreased drug abuse. ies, but it helps provide an answer to the ultimate question: Does this medication help an individual EXAMPLES OF MEDICATIONS USED stop abusing drugs? TO TREAT DRUG ABUSE Several types of medications have been devel- APPROACHES TO DEVELOPING oped for countering various kinds of dependencies. MEDICATIONS FOR DRUG ABUSE Opioid Dependence. Some of the best exam- Researchers can use the knowledge gained from ples of pharmacotherapies for drug abuse were animal and human studies of the effects of drugs on developed for opiate addicts. One of the first phar- the brain as they develop medications for alcohol macological agents used to treat opiate addicts is and drug dependence. Most likely, one medication METHADONE. Methadone itself is an opiate drug will be needed to help detoxify the drug-dependent and effectively reduces or blocks the withdrawal individual and a second medication to help sustain discomfort brought on by discontinuing use of her- abstinence from drug use. This two-phase medica- oin or other illegal opiate. Although methadone is tion regimen is used for opiate and alcohol treat- itself addictive, it is delivered to the opiate-depen- ment, and it may ultimately be the approach used dent patients in a facility with psychological and for countering dependency on other drugs, such as other medical and support treatments and services. cocaine, sedatives, and nicotine. In theory, a phar- Methadone is safer than opiates obtained ille- macological treatment agent or medication would gally—in part because it is given orally. Because block or reduce either the acute, rewarding effect of illegal opiates are often injected by addicts, they the drug or the discomfort of withdrawal. In prac- can lead to many diseases—including AIDS and tice, few treatment drugs have been found to be hepatitis, if the needles are shared with an infected very effective in sustaining abstinence from drugs person. Illegal drug use is expensive, and many or alcohol. addicts steal to support their habit. Moreover, since Any pharmacological agent should be able to be drugs obtained illegally vary in their quality and given orally, as this is much easier than other routes purity, there is a greater chance of getting an over- of administration, such as injections. The agent dose that produces severe medical problems and, itself must be medically safe and not enhance any perhaps, death. Thus methadone decreases the of the health risks associated with illicit drug use, need to use illegal opiates, as a result of its ability to since the individual may illicitly use drugs while relieve withdrawal as well as to block the effects of being maintained on the treatment agent. Finally, other opiates by cross-tolerance. Moreover, it re- the pharmacological treatment agent must be ac- duces the health risks and social problems associ- ceptable to the patient. That is, if the agent causes ated with illegal opiate use. undesirable side effects, individuals will likely not Another treatment drug that was developed for take it. opiate dependence and abuse is naltrexone. This Current research with alcohol and drug effects agent blocks the ability of the opiate drug to act on on the brain and with treatment outcome hold the brain. Thus, if heroin addict maintained on great promise for effective pharmacological agents. naltrexone injects heroin, he or she will not feel the This search process will necessarily include the ani- pleasant or other effects of the heroin. The princi- mal and human laboratory studies mentioned as ple behind this approach is based on research sug- well as medicinal chemistry research. Medicinal gesting that drug use is continued, despite the dire chemistry research is used to develop new com- consequences, because of the euphoria associated pounds that have similar but slightly altered chem- with its use. Once maintained on naltrexone, the ical structures to the abused drugs or to the neuro- addict may forget this association, because the drug 970 RESEARCH: Developing Medications to Treat Substance Abuse and Dependence can no longer produce these effects. Unfortunately, any of these medications are used as maintenance although naltrexone works well for some, others agents. will simply discontinue using the naltrexone in or- Tobacco Dependence. One commonly used der to get high from drugs again. pharmacological treatment for tobacco dependence Before opiate abusers can be maintained on the is NICOTINE GUM (Nicorette). The main reason to medication naltrexone, they must be detoxified quit smoking is that it is linked to lung cancer, from the opiate drugs in their systems. Although emphysema, and other serious illnesses. Yet the ac- abstaining (‘‘cold turkey’’) from heroin use for sev- tive ingredient in cigarettes, NICOTINE, is associated eral days will accomplish detoxification, the with- with pleasant effects and with withdrawal discom- drawal process is difficult because of the physical fort, thereby making it an extremely addicting distress it causes. Thus, another DETOXIFICATION drug. Providing smokers with nicotine replacement method was developed in which the withdrawal is in the form of a gum will help them avoid the health precipitated, or triggered, with naltrexone, while risks associated with cigarettes. One problem with the symptoms are treated with another medication, nicotine gum is that it is difficult to chew correctly; CLONIDINE. When withdrawal is precipitated, the people need to be shown how to chew it in order to symptoms are worse than that seen with natural get the therapeutic effect. A patch is also available withdrawal, but the symptom course is much that is placed on the arm and automatically re- briefer. Moreover, clonidine helps alleviate the leases nicotine. This method shows good treatment symptoms, to make this shorter-term withdrawal potential. Detoxification from nicotine may also be process less severe. facilitated with the medication clonidine, the same Alcohol Dependence. An example of another agent used to help alleviate opiate withdrawal type of medication is one used to treat alcoholism: symptoms. DISULFIRAM. The basis for this agent’s therapeutic Stimulant Dependence. Developing pharma- effect is different from that of methadone or nal- cological treatment agents for stimulant (e.g., co- trexone. When someone is maintained on di- caine) dependence is a difficult task but has been sulfiram, future alcohol ingestion will cause stom- the focus of a great deal of research. One of the ach distress and, possibly, vomiting, because the difficulties for treating cocaine abuse is that cocaine disulfiram prevents the breakdown of a noxious affects many different neurotransmitter systems in alcohol metabolite by the liver. Patients maintained various ways. Thus one approach may be to deon disulfiram should come to forget the pleasant effects of alcohol use, which is similar to the psy- velop a treatment drug or regimen of drugs that chological basis of naltrexone maintenance. More- affects a variety of neurotransmitter systems. How- over, they should begin to develop an aversion to ever, the exact nature of the neural effects of co- alcohol use. Another similarity to the use of nal- caine are still not entirely understood. trexone is that disulfiram treatment of alcoholism Another difficulty is that it is not clear what has not been very successful, because the patient approach to take in developing a treatment drug. who wants to use alcohol again can simply stop One obvious technique in developing a medication using the disulfiram. for cocaine abuse is to use an agent that blocks the Some pharmacological agents have been tested rewarding aspects of cocaine use. This type of drug to reduce craving for alcohol and thus help the would, presumably, decrease cocaine use because alcoholic abstain from drinking. These drugs in- the rewarding effects are no longer experienced. clude naltrexone, which was developed for opiate However, this approach is similar to having opiate addicts, and fluoxetine. The former medication is a addicts use naltrexone, which has not been well potential treatment drug because most drugs of accepted by heroin addicts. Clinical work with abuse are believed to be mediated, in part, through some treatment agents that were suggested to block the brain’s natural opiate system (ENDORPHINS, the rewarding effects of cocaine did not prove to be etc.). Based on research that implicates a specific useful in the treatment of abuse and dependence. neurotransmitter system (SEROTONIN) in alcohol Whether this lack of treatment effect resulted from craving, the latter medication and others of this a flaw in the method or from the limitations in our type may be useful. However, as in the treatment of knowledge of cocaine’s effects on neurotransmitter opiate abuse, alcoholics must be detoxified before systems is not clear. One problem is that the poten- RESEARCH: Drugs as Discriminative Stimuli 971 tial blocking agents for cocaine may produce Moreover, medications that are developed based on dysphoria, or an unpleasant feeling. theoretical principles of altering or blocking the Another approach to treating cocaine abuse and drug’s effects in the brain may not be useful in the dependence is based on a premise similar to that of practice of treating drug abuse and dependence, methadone for opiate abuse. That is, a pharmaco- because the premises of how to develop a pharma- logical agent similar in its effects to cocaine, but cological treatment agent may not be accurate. Yet one that is not addicting, may be a useful an- the largest research challenge is to understand the ticraving agent. Just as methadone helps alleviate etiology and mechanisms of drug abuse. Thus more drug withdrawal, an agent of this type for cocaine research in many fields is needed to identify poten- abuse may alleviate the distress and craving associ- tial medications in order to develop more effective ated with abstinence from cocaine. Several medica- treatments for the difficult problem of drug abuse tions of this type have been tried, including bro- and dependence. mocriptine and AMANTADINE. Thus far, these and other agents have shown some limited treatment (SEE ALSO: Addiction: Concepts and Definitions; promise. Imaging Techniques: Visualizing the Living Brain; Most of the approaches to developing pharmaco- Treatmeat/Treatment Types) logical treatments for cocaine abuse have been based on research suggesting that one specific neu- BIBLIOGRAPHY rotransmitter (DOPAMINE) is important for cocaine’s rewarding effects. Yet other neurotransmit- JAFFE, J. H. (1985). Drug addiction and drug abuse. In ters are activated during cocaine use and may be A. G. Gilman, el al. (Eds.), Goodman and Gilman’s better targets for developing new treatment drugs. the pharmacological basis of therapeutics, 7th ed. That is, although dopamine is critical for the re- New York: Macmillan. warding aspects of cocaine use, other neurotrans- KOSTEN, T. R., & KLEBER,H.D.(EDS.). (1992). Clini- mitter systems may be more important in with- cian’s guide to cocaine addiction. New York: Guilford drawal distress. Although withdrawal distress from Press. cocaine has been difficult to document, depression LIEBMAN, J. L., & COOPER,S.J.(EDS.). (1989). The neu- is thought to be one aspect of abstaining from ropharmacological basis of reward. Oxford: chronic cocaine use. Antidepressant medications, Clarendon Press. such as desipramine and imipramine, have shown LOWINSON, J. H., RUIZ, P., & MILLMAN,R.B.(EDS.). some, albeit limited, treatment potential. (1992). Substance abuse: A comprehensive textbook. Sedative Dependence. Current treatments Baltimore: Williams & Wilkins. for sedative dependence include detoxification MILLER,N.S.(EDS.). (1991). Comprehensive handbook agents, not anticraving agents. Detoxification is ac- of drug and alcohol addiction. New York: Marcel complished by tapering the dosage of BENZODIAZE- Dekker. PINES over two to three weeks. More recently, car- THERESE A. KOSTEN bamazepine, an antiseizure analgesic medication, has been shown to relieve alcohol and sedative withdrawal symptoms, including seizures and de- Human lirium tremens. Future work with agents that block Drugs as DiscriminativeStimuli behavior is influenced by numerous stimuli in the the actions of benzodiazepines may hold promise as a maintenance or anticraving agent to help the environment. Those stimuli acquire behavioral sedative abuser abstain from drug abuse. control when certain behavioral consequences occur in their presence. As a result, a particular behavioral response becomes more or less likely to CONCLUSION occur when those stimuli are present. For example, One of the greatest lessons learned from the several laboratory experiments have demonstrated practice of giving medications to drug-abusing in- that it is possible to increase a particular response dividuals is that these medications must be accom- during a stimulus (such as a distinctively colored panied by psychological and social treatments and light) by arranging for reinforcement (such as a support. Medications do not work on their own. preferred food or drink) to be given following that 972 RESEARCH: Drugs as Discriminative Stimuli response when the stimulus is present; when that the appropriate response following either the train- stimulus is absent, however, responses do not pro- ing drug or the saline administration, it is possible duce the reinforcer. Over a period of time, respond- to investigate aspects of the drug stimulus in the ing will then occur when the stimulus is present but same way as one might investigate other physical not when it is absent. Stimuli that govern behavior stimuli. It is thus possible to determine gradients of in this manner are termed discriminative stimuli intensity or dose-effect functions with the training and have been widely used in behavioral and phar- drug as well as generalization functions aimed at macological research to better understand how be- determining how similar the training drug dose is havior is controlled by various stimuli, and how to a different dose or to another drug substituted those stimuli, in turn, might affect the activity of for the training stimulus. various drugs. It is important to recognize that there are differ- BASIC EXPERIMENTAL RESULTS ences between discriminative stimuli that merely set the occasion for a response to be reinforced and One of the more striking aspects of the drug other types of stimuli that directly produce or elicit discrimination technique is the strong relationship responses. Discriminative stimuli do not coerce a that has been found between the stimulus-general- response from the individual in the same way that a ization profile and the receptor-binding character- stimulus such as a sharp pierce evokes a reflexive istics of the training drug. For example, animals withdrawal response. Instead, discriminative stim- trained to discriminate between a BENZODIAZEPINE uli may be seen as providing guidance to behavior anxiolytic, such as CHLORDIAZEPOXIDE, and saline because of the unique history of reinforcement that solution typically respond similarly to other drugs has occurred in their presence. that also interact with the receptor sites for benzodiazepine ligands. Anxiolytic drugs that produce their effects through other brain mechanisms or DRUGS AS DISCRIMINATIVE STIMULI receptors do not engender responses similar to Although the stimuli that typically govern be- those occasioned by benzodiazepines. This suggests havior are external (i.e., located in the environment that it is activity at a specific RECEPTOR that is outside the skin), it is also possible for internal or established when this technique is used and not the subjective stimuli to influence behavior. One of the action of the drug on a hypothetical psychological more popular methods to emerge in the field of construct such as anxiety (Barrett & Gleeson, behavioral pharmacology has been the use of drugs 1991). as discriminative stimuli. The procedure consists of Several studies have examined the effects of establishing a drug as the stimulus, in the presence drugs of abuse by using the drug discrimination of which a particular response is reinforced. Typi- procedure, and they have established COCAINE and cally, to establish a drug as a discriminative stimu- numerous other drugs—such as an OPIATE, lus, a single dose of a drug is selected and, following PHENCYCLIDINE (PCP), or MARIJUANA—as a dis- its administration, one of two responses are rein- criminative stimulus in an effort to help delineate forced; with rodents or nonhuman primates, this the neuropharmacological or brain mechanisms usually entails pressing one of two simultaneously that contribute to the subjective and abuse-liability available levers, with reinforcement being sched- effects of these drugs. As an example, Figure 1 uled intermittently after a fixed number of correct shows the results obtained in pigeons trained to responses. Alternatively, when saline or a placebo is discriminate a 1.7 milligram per kilogram (mg/kg) administered, responses on the other device are re- dose of cocaine from saline. The dose-response inforced. Over a number of experimental sessions, a function demonstrates that doses below the train- discrimination develops between the administra- ing dose of cocaine yielded a diminished percentage tion of the drug and saline, with the interoceptive of responses on the key correlated with cocaine (subjective) stimuli produced by the drug seen as administration, which suggests that the lower doses guiding or controlling behavior in much the same of cocaine were less discernible than the training manner as any external stimulus, such as a visual or dose. In addition, other psychomotor stimulants auditory stimulus. Once the discrimination has such as AMPHETAMINE and METHAMPHETAMINE also been established, as indicated by the selection of produced cocaine-like responses, and this suggests RESEARCH: Drugs as Discriminative Stimuli 973

that these drugs share some of the neurochemical properties of cocaine. In contrast, other drugs, such ␣ as the 2-adrenoreceptor antagonist yohimbine, along with several other drugs such as morphine, PCP, or marijuana (that are not illustrated) do not produce responding on the key correlated with cocaine administration—thereby suggesting that the mechanisms of action underlying those drugs, as well as their subjective effects, are not similar to those of cocaine and the other psychomotor stimulants in this ﬁgure.

IMPLICATIONS The use of drugs as discriminative stimuli has provided a wealth of information on the way drugs Figure 1 are similar to more conventional environmental Discriminative Stimuli. Effects of establishing a stimuli in their ability to control and modify behav- dose of 1.7 mg/kg cocaine, administered ior. The procedure has also increased our under- intramuscularly, as a discriminative stimulus in pigeons. Following the administration of the standing of the neuropharmacological mechanisms training dose of cocaine, 30 consecutive pecks on that operate to produce the constellation of effects one illuminated response key resulted in food associated with those drugs. The technique has reinforcement, whereas following the wide generality and has been studied in several administration of saline, 30 consecutive pecks on species, including humans—in whom the effects a different key produced food. Once the are quite similar to those of nonhumans. discrimination was established, various doses of Because it is believed that the subjective effects other drugs were substituted for cocaine. The of a drug are critical to its abuse potential, the discriminative stimulus effects of cocaine were study of drugs of abuse as discriminative stimuli dose-dependent, with doses from 0.1 to 1.7 takes on added signiﬁcance. A better understand- producing increases in responding on the key ing of the effects of drugs of abuse as pharmacolog- correlated with the training dose of cocaine. ically subjective stimuli provides a means by which Similarly, d-amphetamine and to evaluate possible pharmacological as well as be- methamphetamine also resulted in responding on havioral approaches to the treatment of drug the cocaine key, thereby showing that these abuse. For example, a drug that prevents or antag- drugs have some of the same subjective stimulus onizes the discriminative-stimulus effects (and pre- properties and presumably sumably the neuropharmacological actions) of an neuropharmacological effects as cocaine. A drug abused drug might be an effective medication to that does not produce generalization, yohimbine, permit individuals to diminish their intake of an ␣2-adrenoreceptor antagonist, resulted only abused drugs, because the stimuli usually associ- in modest levels of responding on the cocaine- ated with its effects will no longer occur. Similarly, associated response key, which suggests that this although little work has been performed on the is not a mechanism by which cocaine produces manipulation of environmental stimuli correlated its subjective behavioral and pharmacological with the drug stimulus, it might be possible to de- effects. sign innovative treatment strategies in which other SOURCE: Adapted from Johnson & Barrett, 1993. stimuli compete with the subjective discriminative- stimulus effects of the abused drug. Thus, a basic experimental procedure such as drug discrimination has provided a useful experimental tool for understanding the behavioral and neuropharmacological effects of abused drugs. 974 RESEARCH: Measuring Effects of Drugs on Behavior

Further work may help design and implement behavior is not so simple. Like any other scientific novel treatment approaches to modifying the be- inquiry, research in this area requires careful de- havioral and environmental conditions surround- scription of the behaviors being examined. If the ing the effects of abused drugs and thus result in behavior is not carefully described, it is difficult to diminished behavioral control by substances of determine whether a change in behavior following abuse. drug administration is actually due to the drug. Behavior is best defined by describing how it is (SEE ALSO: Abuse Liability of Drugs; Drug Types; measured. By specifying how to measure a behav- Research, Animal Model ) ior, an operational definition of that behavior is developed. For example, to study the way in which BIBLIOGRAPHY a drug alters food intake, the following procedure might be used: First, select several people and pres- BARRETT, J. E., & GLEESON, S. (1991). Anxiolytic effects ent each with a box of cereal, a bowl, a spoon, and of 5-HT1A agonists, 5-HT3 antagonists and benzodi- some milk after they wake up in the morning. Then azepines. In R. J. Rodgers & S. J. Cooper (Eds.), measure how much cereal and milk they each con- 5-HT1A agonists, 5-HT3 antagonists and benzodiaze- sume within the next thirty minutes. To make sure pines: Their comparative behavioral pharmacology. the measurements are correct, repeat the observa- New York: Wiley. tions several times under the same conditions (i.e., JOHANSON, C. E., & BARRETT, J. E. (1993). The discrimi- at the same time of day, with the same foods avail- native stimulus effects of cocaine in pigeons. Journal able). From these observations, determine the aver- of Phamacology and Experimental Therapeutics, age amount of milk and cereal consumed by each 267,1–8. person. This is the baseline level. Once the baseline JAMES E. BARRETT level is known, give a small amount of drug and JUNE STAPLETON measure changes in the amount of milk and cereal consumed. Repeat the experiment, using increasing amounts of the drug. This concept of baseline level Measuring Effects of Drugs on Behavior and change from baseline level is common to many People throughout world take drugs such as HER- scientific investigations. OIN,COCAINE, and ALCOHOL because these drugs In addition to defining behavior by describing alter behavior. For example, cocaine alters general how it is measured, a good behavioral procedure is activity levels; it increases wakefulness and de- also (1) sensitive to the ways in which drugs alter creases the amount of food an individual eats. behavior and (2) is reliable. Sensitivity refers to Heroin produces drowsiness, relief from pain, and whether a particular behavior is easily changed as a general feeling of pleasure. Alcohol’s effects in- the result of drug administration. For example, clude relaxation, increased social interactions, food consumption may be altered by using cocaine, marked sedation, and impaired motor function. but other behaviors may not be. Reliability refers to For the most part, the scientific investigations of whether a drug produces the same effect each time the ways drugs alter behavior began in the 1950s, it is taken. In order to say that cocaine reliably when chlorpromazine was introduced as a treat- alters the amount of food consumed, it should de- ment for SCHIZOPHRENIA. As a result of this dis- crease food consumption each time it is given, pro- covery, scientists became interested in the devel- vided that the experimental conditions surrounding opment of new medications to treat behavioral its administration are the same. disorders as well as in the development of procedures for studying behavior in the laboratory. WHAT FACTORS INFLUENCE A DRUG’S EFFECTS ON BEHAVIOR? HOW IS BEHAVIOR STUDIED? Although good behavioral procedures are neces- The simplest way to study the effects of drugs on sary for understanding a drug’s effects on behavior, behavior is to pick a behavior, give a drug, and pharmacological factors are also important deter- observe what happens. Although this approach minants of a drug’s effect. Pharmacological factors sounds very easy, the study of a drug’s effect on include the amount of drug given (the dose), how RESEARCH: Measuring Effects of Drugs on Behavior 975

Figure 1 Risk of Being Involved in a Traffic Accident as a Function of the Amount of Alcohol in the Blood Figure 1 quicklyRisk of Being the drug Involved produces in a its Traffic effects (its onset), the ence the drug effect. These include such factors as timeAccident it takes as a for Function its effects of the to disappear Amount of (its dura- how many times an individual has taken a particu- tionAlcohol), and in thewhether Blood the drug’s effects are reduced lar drug; what happened the last time it was taken; (tolerance) or increased (sensitivity) if it is taken or what one may have heard from friends about a several times. Although this point may seem obvi- drug’s effects. ous, it is often overlooked. It is impossible to describe the behavioral effects of a drug on the basis HOW IS BEHAVIOR STUDIED IN of just one dose of the drug, since drugs can have THE LABORATORY? very different effects, depending on how much of Human behavior is very complex, and it is often the drug is taken. Moreover, the probability that a difficult to examine. Although scientists do conduct drug will produce an effect also depends on the studies on people, many investigations of drug ef- amount taken. As an example, consider Figure 1, fects on behavior are carried out using animals. which shows the risk of being involved in a traffic With animals, investigators have better control accident as a function of the amount of alcohol in a over the conditions in which the behavior occurs as person’s blood. well as better information about the organism’s The way in which a drug is taken is also impor- past experience with a particular drug. Although tant. Cocaine can be taken by injection into the animal experiments provide a precise, controlled veins, by smoking, or by sniffing through the nose. environment in which to investigate drug effects, Each of these routes of administration can produce they also have their limitations. Clearly, they can- different effects. Environmental factors also influ- not research all the factors that influence human ence a drug’s effect. Cocaine might change the behavior. Nevertheless, many of the effects that amount of cereal and milk consumed in the morn- drugs produce on behavior in animals also occur in ing but it might not change the amount consumed humans. Moreover, behavioral studies sometimes at a different time of day or if other types of food require a large number of subjects with the same are available. Finally, individual factors also influ- genetic makeup or with no previous drug experi- 976 RESEARCH: Measuring Effects of Drugs on Behavior ence. It is easier to meet these requirements in presses are measured with an automatic device, animal studies than in studies with people. and changes in responding are examined following Since animals are often used in research studies, drug administration. These procedures have sev- it is important to remember that behavioral scien- eral advantages. First, they produce a very consis- tists are very concerned about the general welfare tent measure of behavior. Second, they can be used of their animals. The U.S. Animal Welfare Act set with human subjects as well as with several differ- standards for handling, housing, transporting, ent animal species. Third, the technology for re- feeding, and veterinary care of a wide variety of cording behavior eliminates the need for a trained animals. In addition, all animal research in the observer. United States is now reviewed by a committee that includes a veterinarian experienced in laboratory- WHAT BEHAVIORS DO animal care. This committee inspects animal-re- DRUGS ALTER? search areas and reviews the design of experiments to ensure that the animals are treated well. Some of the behaviors that drugs alter are motor behavior, sensory behavior, food and water intake, social behavior, and behavior established with clas- WHAT APPROACHES ARE USED TO sical and operant conditioning procedures. By com- EXAMINE DRUG EFFECTS? bining investigations of these behaviors, scientists In general, there are two ways to examine drug classify drugs according to their prominent behav- effects on behavior in the laboratory. One approach ioral effects. For example, drugs such as AMPHET- relies on observation of behavior in an animal’s AMINE and cocaine are classified as PSYCHOMOTOR home cage or in an open area in which the animal STIMULANTS because they increase alertness and (or person) can move about freely. When observa- general activity in a variety of different behavioral tional approaches are used, special precautions are procedures. Drugs such as MORPHINE are classified necessary. First of all, the observer’s presence as analgesics because they alter the perception of should not disrupt the experiment. Television- pain, without altering other sensations such as vi- monitoring systems and videotaping make it possi- sion or audition (hearing). ble for the observer to be completely removed from Motor Behavior. Most behaviorally active the experimental situation. Second, the observer drugs alter motor behavior in some way. Morphine should not be biased. The best way to insure that usually decreases motor activity, whereas with co- the observer is not biased is to make the observer caine certain behaviors occur over and over again ‘‘blind’’ to the experimental conditions; that is, the (that is, repetitively). Other drugs, such as alcohol, observer does not know what drug is given or which may alter the motor skills used in DRIVING a car or subject received the drug. If the study is done in operating various types of machinery. Finally, human subjects, then they also should be blind to some drugs alter exploratory behavior, as measured the experimental conditions. An additional way to by a decrease in motor activity in an unfamiliar make sure observations are reliable is to use more environment. Examination of the many ways in than one observer and compare observations. If which drugs alter motor behavior requires different these precautions are taken, observational ap- types of procedures. Some of these procedures ex- proaches can produce interesting and reliable data. amine fine motor control or repetitive behavior; Indeed, much of what is known about drug effects others simply measure spontaneous motor activity. on motor behavior, food or water intake, and some Although changes in motor behavior can be ob- social behaviors comes from careful observational served directly, most studies of motor behavior use studies. some sort of automatic device that does not depend Another approach uses the procedures of classi- on human observers. One of these devices is the cal and operant conditioning. This involves train- running wheel. The type of running wheel used in ing animals to make specific responses under spe- scientific investigations is similar to the running cial conditions. For example, in a typical wheel in pet cages. This includes a cylinder of some experiment of this sort, a rat is placed in an experi- sort that moves around an axle when an animal mental chamber and trained to press a lever to walks or runs in it. The only difference between a receive food. The number and pattern of lever running wheel in a pet cage and a running wheel in RESEARCH: Measuring Effects of Drugs on Behavior 977

and HALLUCINATIONS.PHENCYCLIDINE (PCP) produces a numbness in the hands and feet. Morphine alters sensitivity to painful stimuli. It is difficult to investigate drug effects on sensory behavior, since changes in sensory behavior cannot be observed directly. In order to determine whether someone hears a sound, one must report having heard it. In animal studies, rats or monkeys are trained to press a lever when they hear or see a given stimulus. Then a drug is given and alterations in responding are observed. If the drug alters re- the laboratory is its size and the addition of a sponding, it is possible that the drug did so by counter that records the number of times the wheel altering sensory behavior; however, care must be turns. Another device for measuring motor behav- taken in coming to this conclusion since a drug ior uses an apparatus that is surrounded by pho- might simply alter the motor response used to mea- tocells. If the animal moves past one of the pho- sure sensory behavior without changing sensory tocells, a beam of light is broken and a count is behavior at all. produced. Yet another way to measure motor be- One area of sensory behavior that has received havior is with video tracking systems. An animal is considerable attention is pain perception. In most placed in an open area and a tracking system deter- procedures for measuring pain perception, a poten- mines when movement stops and starts as well as tially painful stimulus is presented to an organism its speed and location. This system provides a way and the time it takes the organism to respond to to look at unique movement patterns such as repet- that stimulus is observed. Once baseline levels of itive behaviors. For example, small amounts of responding are determined and considered reliable, amphetamine increase forward locomotion, a drug is given. If the time it takes the organism to whereas larger amounts produce repetitive behav- respond to the stimulus is longer following drug iors such as head bobbing, licking, and rearing. administration and if this change is not because the Until recently, this type of repetitive behavior was animal is too sedated to make a response, then the measured by direct observation and description. drug probably has altered pain perception. Although technology for measuring motor be- Among the most common procedures used to havior is very advanced, it is important to remem- measure pain perception is the tail-flick procedure ber that how much drug is given, where it is given, in which the time it takes an animal to remove its and the type of subject to whom it is given will also tail from a heat source is measured prior to and influence a drug’s effect on motor behavior. after administration of a drug such as morphine. Whether a drug’s effects are measured at night or Another commonly used procedure measures the during the day is an important factor. The age, sex, time it takes an animal to lick its paws when placed species, and strain of the animal is also important. on a warm plate or to remove its tail from a con- Whether food and water are available is another tainer of warm water. Thus, an alteration in pain consideration as well as the animal’s previous expe- perception is operationally defined as a change in rience with the drug or test situation. As an exam- responding in the presence of a painful stimulus. It ple, see Table 1, which shows how the effects of is also important to note that the animal, not the alcohol on motor behavior differ depending on the experimenter, determines when to respond or re- amount of alcohol in a person’s blood. move its tail. Also, these procedures do not produce Sensory Behavior. The integration and exe- long-term damage or discomfort that extends be- cution of every behavior an organism engages in yond the brief experimental session. involves one or more of the primary senses, includ- Food and Water Intake. The simplest way to ing hearing, vision, taste, smell, and touch. Obvi- measure food and water intake is to determine how ously, a drug can affect sensory behavior and much an organism eats or drinks within a given thereby alter a number of different behaviors. For period of time. A more thorough analysis might example, drugs such as LYSERGIC ACID DI- also include counting the number of times an or- ETHYLAMIDE (LSD) produce visual abnormalities ganism eats or drinks in a single day, or measuring 978 RESEARCH: Measuring Effects of Drugs on Behavior the time between periods of eating and periods of vironment is unfamiliar. Rats interact more when drinking. Several factors are important in accu- they are in a familiar environment than when they rately measuring food and water intake. For exam- are in an unfamiliar environment. Moreover, an- ple, how much food or water is available to the tianxiety drugs increase social interaction in the organism and when is it available? Is it a food the unfamiliar area. These observational techniques organism likes? When did the last meal occur? can produce interesting data, provided that they In animals, food intake is often measured by are carried out under well-controlled conditions, placing several pieces of pelleted food of a known the behavior is well-defined, and care is taken to weight in their cages. The food that remains after a make sure the observer neither disrupts the on- period of time is weighed and subtracted from the going behavior nor is biased. original amount to get an estimate of how much Classical Conditioning. Classical condition- was actually eaten. Water intake is usually mea- ing was made famous by the work of the Russian sured with calibrated drinking tubes clipped to the scientist Ivan Pavlov in the 1920s. In those experi- front of the animal’s cage or with a device called a ments, Pavlov used the following procedure. First, drinkometer, which counts the number of times an dogs were prepared with a tube to measure saliva, animal licks a drinking tube. An accurate measure as shown in Figure 2. Then Pavlov measured the of fluid intake also requires a careful description of amount of saliva that was produced when food was the surrounding conditions. For example, was fluid given. The amount of saliva not only increased intake measured during the day or during the when food was presented but also when the care- night? Was food also available? What kind of fluid taker arrived with the food. From these careful was available? Was there more than one kind of observations, Pavlov concluded that salivation in fluid available? These procedures are also used to response to the food represented an inborn, innate examine drug intake. If rats are presented with two response that did not require any learning. Because different drinking tubes, one with alcohol, another no learning was required, he called this an with water, they will generally drink more alcohol unlearned (unconditioned) response and the food than water; however, the amount they drink is gen- itself an unlearned (unconditioned) stimulus. The erally not sufficient to produce intoxication or dogs did not automatically salivate, however, when physical dependence. Rats will drink a large the caretaker entered the room; but after the care- amount of alcohol as well as other drugs of abuse such as morphine and cocaine when these drugs are taker and the food occurred together several times, the only liquid available. Indeed, most animals will the presence of the caretaker was paired with (or consume sufficient quantities to become physically conditioned to) the food. Pavlov called the care- dependent on alcohol or morphine. taker the conditioned stimulus and he called the Social Behavior. Behaviors such as aggres- salivation that occurred in the presence of the care- sion, social interaction, and sexual behavior are taker a conditioned response. usually measured by direct experimenter observa- Events in the environment that are paired with tion. Aggressive behavior can be measured by ob- or conditioned to drug delivery can also produce serving the number of times an animal engages in effects similar to the drug itself, much in the same attack behavior when another animal is placed into way that Pavlov’s caretaker was conditioned to its cage. In some cases, isolation is used to produce food delivery. For example, when heroin-depen- aggressive behavior. Sexual behavior is also mea- dent individuals stop taking heroin, they experi- sured by direct observation. In the male rat or cat, ence a number of unpleasant effects, such as rest- the frequency of behaviors such as mounting, in- lessness, irritability, tremors, nausea, and tromission, and ejaculation are observed. Another vomiting. These are called withdrawal or absti- interesting procedure for measuring social behavior nence symptoms. If an individual experiences with- is the social interaction test. In this procedure, two drawal several times in the same environment, then rats are placed together and the time they spend in events or stimuli in that location became paired active social interaction (sniffing, following, with (or conditioned to) the withdrawal syndrome. grooming each other) is measured under different With time, the environmental events themselves conditions. In one condition, the rats are placed in a can produce withdrawal-like responses, just as the familiar environment; in another condition, the en- caretaker produced salivation in Pavlov’s dogs. RESEARCH: Measuring Effects of Drugs on Behavior 979

mals and those that are abused by people, the self- administration procedure is often used to examine drug-taking behavior. In most operant conditioning experiments, animals perform a simple response such as a lever press or a key peck to receive food. Usually the organism has to make a fixed number of responses or to space responses according to some temporal pattern. The various ways of delivering a reinforcer are called schedules of reinforcement. Schedules of Figure 2 reinforcement produce very consistent and reliable Diagram of Pavlov’s Classical Conditioning patterns of responding. Moreover, they maintain Experiment. A tube is attached to the dog’s behavior for long periods of time, are easily salivary duct, and saliva drops into a device that adapted for a number of different animals, and records the number of drops provide a very accurate measure of behavior. Thus, they provide a well-defined, operational measure of behavior, which is used to examine the behavioral Operant Conditioning. About a decade after effects of drugs. Pavlov’s discovery of classical conditioning, an- Motivation, Learning, Memory, and Emo- other psychologist, B. F. Skinner, was developing tion. One of the biggest challenges for behavioral his own theory of learning. Skinner observed that scientists is to develop procedures for measuring certain behaviors occur again and again. He also drug effects on processes such as motivation, emo- observed that behaviors with a high probability of tion, learning, or memory since these behaviors are occurrence were behaviors that produced effects on very difficult to observe directly. Drugs certainly the environment. According to Skinner, behavior alter processes such as these. For example, many ‘‘operates’’ on the environment to produce an ef- drugs relieve anxiety. Other drugs produce feelings fect. Skinner called this process operant condition- of pleasure and well-being; still others interfere ing. For example, people work at their jobs because with memory processes. Given the complexity of working produces a paycheck. In this situation, devised procedures, they are not described in detail working is the response and a paycheck is the here; however, it is important to emphasize that the effect. In other situations, a person does something approach for examining the effects of drugs on to avoid a certain effect. For example, by driving a these complex behaviors is the same as it is for any car within the appropriate speed limit, traffic tick- behavior: First, carefully define the behavior and ets are avoided and the probability of having a describe the conditions under which it occurs. Sec- traffic accident is reduced. In this case, the response ond, give a drug and observe changes in the behav- is driving at a given speed and the effect is avoiding ior. Third, take special care to consider pharmaco- a ticket or an accident. logical factors, such as how much drug is given, If the effect that follows a given behavior in- when the drug is given, or the number of times the creases the likelihood that the behavior will occur drug is given. Fourth, consider behavioral factors, again, then that event is called a reinforcer. Food, such as the nature of the behavior examined, the water, and heat are common reinforcers. Drug ad- conditions under which the behavior is examined, ministration is also a reinforcer. It is well known as well as the individual’s past experience with the that animals will respond on a lever to receive behavior. intravenous injections of morphine, cocaine, and amphetamine, as well as a number of other drugs. SUMMARY Not all drugs are self-administered, however. For example, animals will respond to avoid the presen- To find out how drugs alter behavior, several tation of certain nonabused drugs such as the ANTI- factors are considered. These include the PSYCHOTICS (medications used in the treatment of PHARMACOLOGY of the drug itself as well as an schizophrenia). Because there is a good correlation understanding of the behavior being examined. In- between drugs that are self-administered by ani- deed, the behavioral state of an organism, as well as 980 RESEARCH: Measuring Effects of Drugs on Mood the organism’s past behavior and experience with a tive-effect measures are used to determine whether drug contribute as much to the final drug effect as the drug is perceived and to determine the quanti- do factors such as the dose of the drug and how long tative and qualitative characterization of what is it lasts. Thus, the examination of drug effects on experienced. Although subjective effects can be col- behavior requires a careful description of behavior lected in the form of narrative descriptions, stan- with special attention to the way in which the be- dardized questionnaires have greater experimental havior is measured. Behavioral studies also require utility. For example, they may be used to collect the a number of experimental controls, which assure reports of individuals in a fashion that is meaning- that changes in behavior following drug adminis- ful to outside observers, can be combined across tration are actually due to the drug itself and not subjects, and can provide data that are reliable and the result of behavioral variability. replicable. The measurement of subjective effects through the use of questionnaires is scientifically (SEE ALSO: Addiction: Concepts and Definitions; useful for determining the pharmacologic proper- Aggression and Drugs; Causes of Drug Abuse; ties of drugs—including time course, potency, Pharmacodynamics; Psychomotor Effects of Alco- abuse liability, side effects, and therapeutic utility. hol and Drugs; Reinforcement; Research, Animal Many of the current methods used to measure sub- Model; Sensation and Perception and Effects of jective effects resulted from research aimed at re- Drugs; Tolerance and Physical Dependence) ducing drug abuse.

BIBLIOGRAPHY HISTORY

CARLTON, P. L. (1983). A primer of behavioral pharma- Drug abuse and drug addiction are problems cology. New York: W. H. Freeman. that are not new to contemporary society; they have DOMJAN, M., & BURKHARD, B. (1982). The principles of a long-recorded history, dating back to ancient learning and behavior. Pacific Grove, CA: Brooks/ times. For centuries, various drugs including ALCO- Cole Publishing Co. HOL,TOBACCO,MARIJUANA,HALLUCINOGENS, PIUM OCAINE GREENSHAW, A. J., & DOURISH,C.T.(EDS.). (1987). Ex- O , and C , have been available and used perimental psychopharmacology. Clifton, NJ: Hu- widely across many cultures. Throughout these mana Press. times, humans have been interested in describing GRILLY, D. M. (1989). Drugs and human behavior. Bos- and communicating the subjective experiences that ton: Allyn & Bacon. arise from drug administration. Although scientists HARMACOL JULIEN, R. M. (1988). A primer of drug action. New York: have been interested in the study of P - W. H. Freeman. OGY for many centuries, reliable procedures were not developed to measure the subjective effects of MCKIM, W. A. (1986). Drugs and behavior. Englewood Cliffs, NJ: Prentice-Hall. drugs until recently. Throughout the twentieth century, the U.S. MYERS, D. G. (1989). Psychology. New York: Worth. GOVERNMENT has become increasingly concerned RAY,O.,&KSIR, C. (1987). Drugs, society, & human behavior. St. Louis: Times Mirror/Mosby. with the growing problem of drug abuse. To decrease the availability of drugs with significant SEIDEN, L. S., & DYKSTRA, L. A. (1977). Psychopharma- cology: A biochemical and behavioral approach. New ABUSE LIABILITY, the government has passed increasingly restrictive laws concerning the posses- York: Van Nostrand Reinhold. sion and sale of existing drugs and the development LINDA A. DYKSTRA and marketing of new drugs. The pressing need to regulate drugs that have potential for misuse prompted the government to sponsor research for Measuring Effects of Drugs on Mood the development of scientific methodologies that Subjective effects are feelings, perceptions, and would be useful in assessing the abuse liability of moods that are the personal experiences of an indi- drugs. vidual. They are not accessible to other observers Two laboratories that made major contributions for public validation and, thus, can only be ob- to the development of subjective-effect measures tained through reports from the individual. Subjec- were Henry Beecher and his colleagues at Harvard RESEARCH: Measuring Effects of Drugs on Mood 981

University and the government-operated Addiction unipolar (example: ‘‘tired,’’ rated from no effect to Research Center (ARC) in Lexington, Kentucky. extremely), or they may be bipolar (example: Beecher and his colleagues at Harvard conducted a ‘‘tired/alert,’’ with ‘‘extremely tired’’ at one end, lengthy series of well-designed studies that com- ‘‘extremely alert’’ at the other, and ‘‘no effect’’ in pared the subjective effects of various drugs— the center). Another frequently used format is the opiates, sedatives, and stimulants—in a variety of binomial scale, usually in the form of yes/no or subject populations that included patients, sub- true/false responses, such as the Addiction Re- stance abusers, and normal volunteers and high- search Center Inventory. A fourth format utilizes a lighted the importance of studying the appropriate nominal scale, in which the response choices are patient population. Additionally, this group laid categorical in nature and mutually exclusive of the foundation for conducting studies with solid each other (e.g., drug class questionnaire). experimental designs, which include double-blind Questionnaires. Frequently used subjective- and placebo controls, randomized dosing, and effect measures include investigator-generated characterization of dose-response relationships. In- scales, such as adjective-rating scales, and stan- vestigators at the ARC conducted fundamental dardized questionnaires, such as the Profile of studies of both the acute (immediate) and chronic Mood States and the Addiction Research Center (long-term) effects of drugs, as well as physical Inventory. A description of a number of question- dependence and withdrawal symptoms (e.g., Him- naires follows; however, this list is illustrative only melsbach’s opiate withdrawal scale). A number of and is not meant to be exhaustive. questionnaires and procedures now in use to study Adjective Rating Scales. These are questionnaires the subjective effects of drugs were developed, inon which subjects rate a list of symptoms, describ- cluding the Addiction Research Center Inventory ing how they feel or effects associated with drug and the Single Dose Questionnaire. Although many ingestion. The questionaires can be presented to of the tools and methods developed at the ARC are subjects with either visual-analog or ordinal scales. still in use, other laboratories have since modified Items can be used singly or grouped into scales. and expanded subjective-effect measures and their Some adjective-type scales are designed to measure applications. global effects, such as the strength of drug effects or the subject’s liking of a drug, while other adjective rating scales are designed to measure specific drug- MEASURES induced symptoms. In the latter use, the adjectives Question Format. Subjective-effects mea- used may depend on the class of drugs being stud- sures are usually presented in the form of groups of ied and their expected effects. For example, studies questions (questionnaires). These questions can be of amphetamine include items such as ‘‘stimu- presented in a number of formats, the most fre- lated’’ and ‘‘anxious,’’ while studies of opioids in- quently used of which are ordinal scales and visual clude symptoms such as ‘‘itching’’ and ‘‘talkative.’’ analog scales. The ordinal scale is a scale of ranked To study physical dependence, symptoms associ- values in which the ranks are assigned based upon ated with drug withdrawal are used; for example, the amount of the measured effect that is experi- in studies of opioid withdrawal, subjects might rate enced by each individual. Subjects are usually ‘‘watery eyes,’’ ‘‘chills,’’ and ‘‘gooseflesh.’’ Most asked to rate their response to a question on a 4- or adjective-rating scales have not been formally vali- 5-point scale (e.g., to rate the strength of the drug dated; investigators rely on external validity. a little; 2 Profile of Mood States (POMS). This questionnaire ס not at all; 1 ס effect from 0 to 4, with 0 -ex- was developed to measure mood effects in psychiat ס quite a bit; and 4 ס moderately; 3 ס tremely). A visual-analog scale is a continuous ric populations and for use in testing treatments for scale presented as a line without tick marks or psychiatric conditions such as depression and anxi- sometimes with tick marks to give some indication ety. It is a form of an adjective-rating scale. This of gradations. A subject indicates the response by scale was developed by Douglas McNair, Ph.D., placing a mark on that line, according to a particu- and has been modified several times. It exists in two lar reference point; for example, lines are usually forms—one consisting of sixty-five and another of anchored at the ends with labels such as ‘‘not at seventy-two adjectives describing mood states that all’’ and ‘‘extremely.’’ Visual-analog scales can be are rated on a five-point scale from ‘‘not at all’’ (0) 982 RESEARCH: Measuring Effects of Drugs on Mood to ‘‘extremely’’ (4). The item scores are weighted ethylamide Group (LSDG) to measure dysphoria and grouped by factor analysis into a number of or somatic discomfort. The use of the MBG, subscales, including tension-anxiety, depression- PCAG, and LSDG scales has remained standard in dejection, anger-hostility, vigor, fatigue, confusion- most studies of abuse liability. Subscales on this bewilderment, friendliness, and elation. This ques- questionnaire were developed empirically, fol- tionnaire has been used to measure acute drug ef- lowed by extensive validation studies. fects, usually by comparing measures collected be- Observer-rated Measures. These may frequently fore and after drug administration. Its use in drug accompany the collection of subjective effects and studies has not been formally validated; however, it are often based on the subjective-effect question- has been validated by replication studies in normal naires. Ratings are made by an observer who is and psychiatric populations and in treatment stud- present with the subject during the study, and ies. items are limited to those drug effects that are ob- Single Dose Questionnaire. This was developed in servable. Observer-rated measures may include the 1960s at the ARC to quantify the subjective drug-induced behaviors (e.g., talking, scratching, effects of opioids. It has been used extensively and activity levels, and impairment of motor function), has been modified over time. This questionnaire as well as other drug signs such as redness of the consists of four parts; (1) a question in which sub- eyes, flushing, and sweating. Observer-rated mea- jects are asked whether they feel a drug effect (a sures can be designed using any of the formats used binomial yes/no scale); (2) a question in which in subject-rated measures. Examples of observer- subjects are asked to indicate which among a list of rated questionnaires that have been used exten- drugs or drug classes is most similar to the test drug sively are the Single Dose Questionnaire, which (a nominal scale); (3) a list of symptoms (checked exists in an observer-rated version, and the Opiate yes or no); and (4) a question asking subjects to Withdrawal Scale developed by Himmelsbach and rate how much they like the drug (presented as an his colleagues at the ARC. ordinal scale). The list of drugs used in the questionnaire includes placebo, opiate, stimulant, mari- USES OF SUBJECTIVE-EFFECT juana, sedative, and other. Examples of symptoms MEASURES listed are turning of stomach, skin itchy, relaxed, sleepy, and drunken. While this questionnaire has The methodology for assessing the subjective not been formally validated, it has been used effects of drugs was developed, in large part, to widely to study opioids, and the results have been characterize the abuse liability, the pharmacologi- remarkably consistent over three decades. cal properties, and the therapeutic utility of drugs. Addiction Research Center Inventory (ARCI). This Abuse liability is the term for the likelihood that a is a true/false questionnaire containing more than drug will be used illicitly for nonmedical purposes. 550 items. The ARCI was developed by research- The assessment of the abuse-liability profile of a ers at the ARC to measure a broad range of physi- new drug has historically been studied by compar- cal, emotive, and subjective drug effects from di- ing it with a known drug, whose effects have been verse pharmacological classes. Subscales within previously characterized. Drugs that produce eu- the ARCI were developed to be sensitive to the phoria are considered more likely to be abused than acute effects of specific drugs or pharmacological drugs that do not produce euphoria. classes (e.g., morphine, amphetamine, barbitu- Subjective-effects measures may also be used to rates, marijuana); feeling states (e.g., tired, excite- characterize the time course of a drug’s action ment, drunk); the effects of chronic drug adminis- (such as time to drug onset, time to maximal or tration (Chronic Opiate Scale); and drug peak effect, and the duration of the drug effect). withdrawal (e.g., the Weak Opiate Withdrawal These procedures can provide information about and Alcohol Withdrawal Scale). The ARCI the pharmacological properties of a particular subscales most frequently used in acute drug-ef- drug, such as its drug class, whether it has AGONIST fect studies are the Morphine-Benzedrine Group or ANTAGONIST effects, and its similarity to proto- (MBG) to measure euphoria; the Pentobarbital- typic drugs within a given drug class. Subjective- Chlorpromazine-Alcohol Group (PCAG) to mea- response reports are also useful in assessing the sure apathetic sedation; and the Lysergic Acid Di- efficacy (the ability of a drug to produce its desired RESEARCH: Measuring Effects of Drugs on Mood 983

effects), potency (amount or dose of a drug needed CONCLUSION to produce that effect), and therapeutic utility of a Measures of the subjective effects of drugs have new drug. Subjective reports provide information been extremely useful in the study of pharmacol- regarding the potency and efficacy of a new drug in ogy. Questionnaires have been developed that are comparison to available treatment agents. Subjec- sensitive to both the global effects and the specific tive-effect measures may be useful in determining effects of drugs; however, research is still underway whether a drug produces side effects that are dan- to develop even more sensitive subjective-effect gerous or intolerable to the patient. Drugs that pro- measures and new applications for their use. duce unpleasant or dysphoric mood-altering effects may have limited therapeutic usefulness. (SEE ALSO: Abuse Liability of Drugs; Addiction: Concepts and Definitions; Causes of Substance DESCRIPTION OF MAJOR FINDINGS Abuse; Drug Types) OBTAINED WITH DIFFERENT DRUG CLASSES BIBLIOGRAPHY Drugs of different pharmacological classes generally produce profiles of subjective effects that are BEECHER, H. K. (1959). Measurement of subjective re- unique to that class of drugs and that are recogniz- sponses: Quantitative effects of drugs. New York: Ox- able to individuals. The subjective effects of major ford University Press. pharmacological classes have been characterized DEWIT, H., & GRIFFITHS, R. R. (1991). Testing the abuse using the questionnaires described above. Table 1 liability of anxiolytic and hypnotic drugs in humans. lists some major pharmacological classes and their Drug and Alcohol Dependence, 28(1), 83–111. typical effects on various instruments. While global FOLTIN, R. W., & FISCHMAN, M. W. (1991). Assessment measures provide quantitative information regard- of abuse liability of stimulant drugs in humans: A ing drug effects, they tend not to differentiate methodological survey. Drug and Alcohol Depen- among different types of drugs. Nevertheless, the dence, 28(1), 3–48. more specific subjective-effect measures, such as MARTIN, W. R. (1977a). Drug addiction I. Berlin: the ARCI and the Adjective Rating Scales, yield Springer-Verlag. qualitative information that can differentiate MARTIN, W. R. (1977b). Drug addiction II. Berlin: among drug classes. Springer-Verlag. 984 RESEARCH: Motivation

PRESTON, K. L., & JASINSKI, D. R. (1991). Abuse liability the second phase are associated with the object studies of opioid agonist-antagonists in humans. Drug giving rise to these positive sensations and the envi- and Alcohol Dependence, 28(1), 49–82. ronmental stimuli identified with the object. The KENZIE L. PRESTON critical third stage involves processes by which sa- SHARON L. WALSH lience is attributed to subsequent perceptions of the natural incentive stimulus and the associated environmental cues. It is postulated that this attribution of ‘‘incentive salience’’ depends upon activation of Motivation Motivation is a theoretical con- the mesotelencephalic dopamine systems. The sen- struct that refers to the neurobiological processes sation of pleasure and the classical associative responsible for the initiation and selection of such learning processes that mediate stages one and two goal-directed patterns of behavior as are appropri- respectively are subserved by different neural ate to the physiological needs or psychological de- substrates. sires of the individual. Effort or vigor are terms used In the context of drive states as the physiological to describe the intensity of a specific pattern of substrates of motivation, the level of motivation is motivated behavior. Physiological ‘‘drive’’ states, manipulated by deprivation schedules in which the caused by imbalances in the body’s homeostatic subject is denied access mainly to food or water for regulatory systems, are postulated to be major de- fixed periods of time (e.g., twenty-two hours of terminants of different motivational states. Depri- food deprivation). An animal’s increased motiva- vation produced by withholding food or water is tion can be inferred from measures such as its run- used routinely in studies with experimental animals ning speed in a runway to obtain food reward. to establish prerequisite conditions in which nutri- Under these conditions, speed is correlated with ents or fluids can serve as positive reinforcers in level of deprivation. Another measure of the moti- both operant and classical conditioning proce- vational state of an animal is the amount of work dures. In more natural conditions, the processes by expended for a given unit of food, water, or drug. which animals seek, find, and ingest food or fluids Work here is defined as the number of lever presses are divided into appetitive and consummatory per reinforcer. If one systematically obtains an in- phases. Appetitive behavior refers to the various crease in the number of presses, one can identify a patterns of behavior that are used to locate and specific ratio of responses per reward beyond which bring the individual into direct contact with a bio- the animal is unwilling to work. This final ratio is logically relevant stimulus such as water. Consum- called the break point. In the context of drug rein- matory behavior describes the termination of ap- forcement, the break point in responding for CO- proach behavior leading subsequently to ingestion CAINE can be increased or decreased in a dose- of food, drinking of fluid, or copulation with a dependent manner by dopamine agonists and an- mate. tagonists respectively. Incentive motivation is the term applied to the Appetitive behavior also can be measured di- most influential psychological theory that explains rectly in animal behavior studies either by an ani- how the stimulus properties of biologically relevant mal’s latency (the time it takes) in approaching a stimuli, and the environmental stimuli associated source of food or water during presentation of a with them, control specific patterns of appetitive conditioned stimulus predictive of food, or simply behavior (Bolles, 1972). According to this theory, by measuring the animal’s latency approaching a the initiation and selection of specific behaviors are food dispenser when given access to it. The fact that triggered by external (incentive) stimuli that also these appetitive behaviors are disrupted by dopa- guide the individual toward a primary natural in- mine antagonists has been interpreted as evidence centive, such as food, fluid, or a mate. Drugs of of the role of mesotelencephalic dopamine path- abuse and electrical brain-stimulation reward can ways in incentive motivation. serve as artificial incentives. In a further refinement In extending these ideas to the neural bases of of this theory, Berridge and Valenstein (1991) de- drug addiction, Robinson and Berridge (1993) em- fined incentive motivation as the final stage in a phasized the role of sensitization, or enhanced be- three-part process. The first phase involves the ac- havioral responses to fixed doses of addictive drugs, tivation of neural substrates for pleasure, which in that occurs after repeated intermittent drug treat- RESEARCH, ANIMAL MODEL: An Overview of Drug Abuse 985 ment. Neurobiological evidence indicates that sen- Drug Effects; Learning Modifier Drug Effects; Oper- sitization is directly related to neuroadaptations in ant Learning Is Affected by Drugs. the mesotelencephalic dopamine systems. As a re- See also Aggression and Drugs: Research Issues; sult of these neural changes, a given dose of am- Motivation and Incentives; and the articles in the phetamine, for example, causes enhanced levels of section entitled Research. extracellular dopamine and an increase in the behavioral effects of the drug. Given the role proposed for the mesotelencephalic DOPAMINE systems An Overview of Drug Abuse A great deal in incentive salience, it is further conjectured that of biomedical research is based on the belief that craving, or exaggerated desire for a specific object only through careful scientific analysis will we or its mental representation, is a direct result of achieve a sound understanding of the problem of drug-induced sensitization. In this manner, re- drug abuse and how to control it. Animal models of peated self-administration of drugs of abuse, such a human condition are an integral part of that as AMPHETAMINE, produce neural effects that set analysis. Animal models were developed to help us the stage for subsequent craving for repeated access understand the factors that control drug abuse. to the drug. Under laboratory conditions it is possible to control many factors, such as the environment, genetics, (SEE ALSO: Brain Structures and Drugs; Causes of drug history, and behavioral history, that cannot Substance Abuse; Research, Animal Model ) easily be controlled outside the laboratory. When these factors can be controlled, their influence on BIBLIOGRAPHY drug abuse can be precisely determined. As always, the use of animals involves the assumption that the BERRIDGE, K. C., & VALENSTEIN, E. S. (1991). What psy- behavior of animals is a valid model of a human chological process mediates feeding evoked by electri- disorder. The drug abuse research that has been cal stimulation of the lateral hypothalamus? Behav- conducted to this point makes it clear that this is a ioral Neuroscience, 105, 3–14. valid assumption. BOLLES, R. C. (1992). Reinforcement, expectancy and There are three major animal models of aspects learning. Psychology Reviews, 79, 394–409. of drug abuse to consider: PHYSICAL DEPENDENCE, ROBINSON, T. E., & BERRIDGE, K. C. (1993). The neural drug self-administration, and drug discrimination. basis of drug craving: An incentive-sensitization the- Each of these has provided basic information about ory of addiction. Brain Research Reviews, 18, 247– the fundamental processes that control drug abuse. 291. In addition, each has provided practical informa- ANTHONY G. PHILLIPS tion about the abuse potential of new drugs. Infor- mation on both of these topics represents an important contribution of animal research to solving the problems of drug abuse. RESEARCH, ANIMAL MODEL The articles in this section describe studies of the effects of drugs on animals in the laboratory. These studies PHYSICAL DEPENDENCE are important because many of our current beliefs Often when a drug is administered repeatedly, about the nature of drug dependence involve con- TOLERANCE develops to its effects. That is, the dose cepts of learning and reinforcement, and many re- of drug that is taken must be increased to achieve cently developed treatments are founded on these the same effect. With prolonged exposure to high beliefs. The section contains An Overview of Drug doses, physical (or physiological) dependence may Abuse research using animal models and detailed develop. That is, the person is dependent on the articles on various research concepts beings ex- drug for normal physiological functioning. The explored in this way: Conditioned Place Preference; istence of physical dependence is revealed when Conditioned Withdrawal; Drug Discrimination drug administration is stopped. When the drug is Studies; Drug Self-Administration; Environmental no longer administered, various physical changes Influences on Drug Effects; Learning, Conditioning, begin to appear. Depending on the specific drug, and Drug Effects—An Overview; Learning Modifies these could include autonomic signs (e.g., diarrhea 986 RESEARCH, ANIMAL MODEL: An Overview of Drug Abuse and vomiting), somatomotor signs (e.g., exagger- ability to produce physical dependence when it is ated reflexes, convulsions), and behavioral signs administered repeatedly. A drug that produces no (e.g., decreases in food and water intake). These physical dependence of its own is clearly a candi- effects have been called withdrawal but in the liter- date for further development. ature are also known as abstinence syndrome. Literally hundreds of new opioid drugs have Historically, it was believed that physical depen- been evaluated in animals for their capacity to pro- dence was the cause of drug addiction. That is, it duce physical dependence, and, in the process, we was felt that one had to become physically depen- have learned much about physical dependence. It is dent on a drug before abuse would occur and that clear that the higher the drug dose and the more the drug dependence or addiction was motivated by frequent the exposure, the more intensive the phys- the need to relieve the abstinence syndrome. One of ical dependence that develops. But recent research the major contributions of modern drug abuse re- with human subjects has strongly suggested that search has been to make it clear that this is not true. even a single dose of an opioid may produce some In fact, much drug abuse occurs in people who are level of physical dependence. Research has also not physically dependent. Nevertheless, since the shown that drugs that suppress the signs of mor- need to avoid the abstinence syndrome can increase phine abstinence in a dependent animal generally the likelihood that a person will continue to abuse a have morphine-like effects themselves. That is, drug, it is important that we understand physical they suppress respiration and cough, kill pain, and dependence. Also, it would be desirable for new have the potential to be abused and produce physi- drugs that are developed not to produce physical cal dependence. These drugs are known as opioid dependence. agonists. Other drugs, known as opioid ANTAGO- The development of physical dependence is most NISTS, may cause abstinence signs and symptoms to common with the OPIOIDS (morphine and mor- appear. Opioid antagonists do not have morphine- phine-like drugs) and central nervous system like effects themselves but are capable of blocking (CNS) depressants (e.g., BARBITURATES and ALCO- or reversing the effects of morphine and morphine- HOL). Since opioids are very valuable painkillers like drugs. Still other drugs, called mixed AGONIST- but produce physical dependence when used re- ANTAGONISTS, can have either type of effect, de- peatedly, there has been great interest in the devel- pending on dose and whether the animal is physi- opment of drugs that can kill pain but do not cally dependent. This group of drugs has proven produce physical dependence. Standard ap- particularly interesting in terms of its contribution proaches to testing new opioids in animals for their to our understanding of how opioids work. In addi- potential for inducing physical dependence have tion, many of them are effective analgesics with been developed. In the early stages of testing, a new apparently low potential to produce physical drug that has been found to be an effective dependence. ANALGESIC is given to an animal that is physically Other classes of drugs besides opioids produce dependent on morphine (mice, rats, dogs, and physical dependence in animals as well. Many of monkeys have been used). After giving the drug, a the basic findings about physical dependence on trained observer scores the occurrence, intensity, CNS depressants (e.g., dose and frequency) are and duration of abstinence signs such as shivering, similar to what has been found with opioids. How- restlessness, irritability, abdominal cramps, vomit- ever, the abstinence syndrome can be even more ing, diarrhea, and decreased eating and drinking. severe than that seen with opioids. HALLUCINA- The drug may not affect the abstinence syndrome; TIONS and even life-threatening convulsions can it may relieve it or it may make the syndrome develop when long-term abuse of a barbiturate or worse. A drug that relieves morphine abstinence alcohol is stopped. Abstinence syndromes have also probably will produce morphine-like physical de- been found after long-term exposure to pendence and may not be considered for further TETRAHYDROCANNABINOL (THC), the active ingre- development on this basis. On the other hand, a dient in MARIJUANA, and PHENCYCLIDINE (PCP). drug that has no effect on abstinence, or even On the other hand, the abstinence syndrome that makes it worse, probably will not produce mor- follows long-term exposure to such CNS stimulants phine-like physical dependence and may be worth as AMPHETAMINE or COCAINE is, by comparison, pursuing. Often such a drug will be evaluated for its mild. RESEARCH, ANIMAL MODEL: An Overview of Drug Abuse 987

DRUG SELF-ADMINISTRATION electric pump and injects a drug solution through the catheter into the vein. In this way, the animal The distinguishing characteristic of drug abuse model mimics intravenous drug injection by hu- is the behavior of drug self-administration. When mans using a syringe. Since taste is not a factor and that behavior becomes excessive and has adverse onset of drug action is rapid, conditioning animals consequences for the individual or society, the indi- to inject drugs by the intravenous route has proven vidual is considered to be a drug abuser. Therefore, relatively straightforward. the development of animal models for studying Reliable methods for administering drugs to ani- drug self-administration was the essential first step mals by inhalation are important for studying the toward identifying factors that control the behav- abuse of drugs that are inhaled, such as TOBACCO, ior. Humans consume drugs by several different SOLVENTS,orCRACK. Methods for studying solvent routes of administration, including oral (e.g., alco- inhalation have been available for several years. hol), intravenous (e.g., cocaine and heroin), and Usually an animal is given the opportunity to press inhalation (e.g., nicotine and crack cocaine). Al- a lever to deliver a brief bolus of solvent vapor to though some of the factors that control drug abuse the area around its nose. Methods for studying may be independent of the route of administration, crack cocaine smoking in monkeys have only re- others may not. Therefore, it has been important to cently been developed. Monkeys are first trained to develop models in which animals self-administer suck on a drinking tube; then the apparatus is drugs by each of these routes. arranged so that sucking on the tube delivers crack Early attempts to study drug self-administration smoke to the monkey. Although the technique is in animals involved oral self-administration. Oral new, it shows promise for the study of smoking in self-administration of drugs has proven difficult to laboratory animals. establish in laboratory animals, probably because Research using these animal models has shown most drug solutions have a bitter taste. Also, when that, with few exceptions, animals self-administer consumed orally, the onset of the drug effect is the same drugs that humans abuse and show simi- relatively slow, making it difficult for the animal to lar patterns of intake. For example, when given make the association between drinking and drug unlimited access to stimulants like amphetamine, effect. For these reasons, when first given a choice both humans and animals alternate periods of between water and a drug solution, most animals high drug intake with periods of no drug intake. In choose the water. However, conditions can be ar- the case of heroin, both animals and humans grad- ranged so that the animal drinks large amounts of ually increase drug intake to levels that are then the drug solution in relatively short periods, by stable for months and even years. In addition, ani- making the drug solution available when food is mals do not self-administer drugs that humans do available, either as a meal or delivered repeatedly not abuse (e.g., aspirin) and even avoid those that as small pellets of food. After a period of drug con- humans report to be unpleasant (e.g., sumption in association with food, food can be ANTIPSYCHOTIC DRUGS). These basic findings vali- removed from the experiment and the animal will date this as an excellent animal model of drug continue to consume the drug orally. When given a abuse by humans. The exceptions are the halluci- choice between the drug solution and water, the nogens and marijuana, which animals do not read- animal will prefer the drug solution. This approach ily self-administer. has been particularly important for research with Research using the self-administration model alcohol, since humans abuse this drug orally. has increased our understanding of drug abuse in To study intravenous self-administration, an an- several different areas. It has become clear that imal is surgically implanted with a chronic intrave- drug self-administration is controlled by events nous catheter through which a drug can be admin- that are initiated inside (e.g., a drug-induced istered. The animal wears a backpack and tether change in brain chemistry) or outside (e.g., stress) that protect the catheter and attach to a wall of the the organism. With regard to events initiated inside cage. The cage usually has levers that the animal the organism, we have begun to learn about the can press to receive a drug injection and lights that NEUROTRANSMITTER systems in the brain that are can be turned on to signal that a drug injection is activated when drugs are self-administered. These available. At that time, a lever press turns on an changes are probably responsible for producing the 988 RESEARCH, ANIMAL MODEL: An Overview of Drug Abuse drug effect that people find desirable and that individual in an environment in which a drug is maintains their self-administration (the reinforcing available and in which conditions encourage drug effect). A substantial amount of recent research has self-administration is more likely to be a drug focused on the neurotransmitter changes that are abuser than one in which environmental conditions involved in the reinforcing effect of cocaine. It has discourage drug abuse. been known for some time that cocaine increases the concentration of certain neurotransmitters in DRUG DISCRIMINATION synapses. Research indicates that it is this effect on certain synapses in the CNS that use the neuro- When a person takes a drug of abuse, it has transmitter DOPAMINE in the brain that almost cer- effects that the person feels and can describe. These tainly plays the primary role in cocaine’s reinforc- effects are called subjective effects (versus objective ing effect. Similar research suggests that the effects that can be seen by an observer), and they neurotransmitter SEROTONIN may play a primary play an important role in drug abuse. A person is role in the effects of alcohol. more likely to abuse a drug that has effects that the Even though neurotransmitter changes occur person describes as pleasant than one that the per- when an individual self-administers a drug, they son describes as unpleasant. are not always sufficient to maintain drug self-ad- The subjective effects of drugs of abuse have ministration or to make it excessive. Events initi- been studied in humans for many years and in ated outside the organism—that is, environmental several different ways. Early research involved ad- events—can increase or decrease drug self-admin- ministering drugs, usually morphine-like drugs, to istration. In the case of alcohol, for example, con- former heroin addicts who then answered question- sumption can be increased in animals simply by naires that were designed to detect and classify the presenting other things of value (e.g., food pellets) subjective effects of the drug. The single-dose opi- every few minutes. Although it is not known exactly ate questionnaire asks the subject whether he or she why this occurs, analogous conditions may increase can feel the drug, to identify the drug, to describe the consumption of alcohol and other drugs by the symptoms, and to rate how much he or she likes some humans. Drug self-administration can also be it. The Addiction Research Center Inventory con- decreased by environmental conditions. For exam- sists of a series of true-false statements that de- ple, increasing the cost of a drug or the effort re- scribe internal states that might be produced by quired to obtain it decreases consumption. Drug drugs. The Profile of Mood States is a list of adjec- self-administration can also be decreased by im- tives that can be used to describe mood. Responses posing punishment or by making valuable alterna- to these questionnaires depend on variables such as tives to drug self-administration available. type of drug and drug dose. Recent research has Animal research has also made it clear that cer- examined the subjective effects of a wider variety of tain individuals may, because of their genetic drugs (including stimulants and depressants) not makeup, be more susceptible to the effects of alco- only in experienced but also inexperienced subjects. hol or other drugs. For example, genetically differ- The purpose of this research is to understand the ent strains of rats can differ in their sensitivity to factors that can influence a person’s subjective re- the effects of codeine, morphine, or alcohol. Also, sponse to drugs of abuse. animals can be selectively bred to be more or less Since subjective effects require a verbal descrip- sensitive to the effects of a drug. These findings tion of an internal state, they can be directly stud- clearly demonstrate a genetic component to drug ied only in humans. Over the past twenty to thirty sensitivity. Research suggests that these animals years, however, it has become clear that animals differ in the amounts of these drugs that they will can be trained to respond in a way that suggests self-administer. How broadly this conclusion cuts they can detect the internal state produced by a across drugs of abuse is unknown but is an active drug. The behavioral paradigm is called DRUG DIS- area of research. CRIMINATION, and the drug effect is called a dis- In short, drug abuse research with animals has criminative stimulus effect. Although a number of made it clear that whether drug self-administration drug-discrimination paradigms have been devel- occurs depends on an interaction between a drug, oped, the most common is a two-lever paradigm in an organism, and an environment. A susceptible which the animal is trained to press one lever after RESEARCH, ANIMAL MODEL: An Overview of Drug Abuse 989 it has received a drug injection and the second lever used for predicting some aspect of the abuse liabil- after an injection of the drug vehicle or, in some ity of new drugs. However, the task is not simply a cases, another drug. Responding on the lever that is matter of detecting abuse liability and making the appropriate to the injection is reinforced, usually drug unavailable. ABUSE LIABILITY must be consid- by presenting a food pellet, while responding on the ered in the context of any potential therapeutic use incorrect lever is not. If this is done repeatedly over of the drug, and a cost-benefit analysis that weighs a period of several weeks, the animal learns to reliability for abuse against therapeutic benefits spond almost exclusively on the lever associated should be made. with the injection. Although it is impossible to Opioids are an excellent example of these con- know what an animal feels, it seems as if the animal siderations. Morphine is often the only appropriate is reporting whether it feels the drug by the lever it analgesic for intense PAIN. However, it produces presses. The animal can then be asked to ‘‘tell’’ us physical dependence and has a high potential for whether a new drug ‘‘feels’’ like the training drug. abuse. A drug that produces analgesia equivalent to It will respond on the drug lever if the new drug is or greater than that of morphine but does not pro- similar to the training drug and on the vehicle lever duce physical dependence would be a highly desir- if it is not. It can also be ‘‘asked’’ whether a drug able compound. Techniques for establishing this blocks the effects of the training drug. If the test have been described in related articles. A new drug drug blocks the effect of the training drug, it will can be tested for its ability to suppress abstinence respond on the vehicle lever when given both drugs. syndrome in monkeys that are dependent on mor- There is a strong correspondence between the phine and for its ability to produce physical depen- classification of drugs by humans based on their dence of its own type in naive animals. A similar subjective effects and those by animals based on approach is taken with the drug in drug self-ad- their discriminative stimulus effects. Research us- ministration experiments. We may ask whether the ing the drug-discrimination model has increased drug maintains self-administration in experienced our understanding of control of behavior by drugs monkeys or whether naive monkeys will initiate in several different ways. First, this research has self-administration. In addition, we can evaluate made it clear that behavior that is learned under whether the drug is likely to be preferred to mor- the influence of a drug is more likely to occur again phine by allowing an animal to choose between when the drug or a similar drug is taken again. This morphine and the new drug or determining how is a fundamental mechanism by which drugs con- hard the animal will work to receive an injection of trol behavior. As with drug self-administration, a the drug relative to how hard it will work for mor- substantial amount of recent research has focused phine. Finally, we can ask whether the drug has on the neurotransmitter changes that are involved discriminative stimulus effects that are similar to in the discriminative stimulus effects of cocaine and those of morphine or of any other drug of abuse. A alcohol. Again, dopamine seems to play a promi- drug that supports physical dependence, is self- nent role in this effect of cocaine, while serotonin administered, and has morphine-like discrimina- may mediate the effects of alcohol. Environmental tive stimulus effects is likely to have high potential events, by contrast, do not seem to alter the dis- for abuse in humans and unlikely to be a viable criminative stimulus effects of drugs substantially. substitute for morphine. On the other hand, a drug However, little research has been done in this area. that lacks one or more (preferably all) of these effects may be worth pursuing. Animal models of drug abuse have been used for ABUSE LIABILITY TESTING AND the development of drugs that may be useful in the TREATMENT RESEARCH treatment of drug abuse. In some ways it seems One important application of animal models of unusual to suggest treating a drug abuse problem drug abuse is the prediction of the likelihood that a with another drug. However, in the case of opioids, new drug will be abused if it is made available to METHADONE, a morphine-like agonist, has proven people. Clearly, the prevalence of abuse of a drug to be quite useful in the treatment of opioid depen- can be reduced by restricting its availability, and dence. Although the drug is still self-administered drugs with high potential for abuse should be the and physical dependence is maintained, treatment least available. All the models discussed here are with methadone allows the person to lead a rela- 990 RESEARCH, ANIMAL MODEL: Conditioned Place Preference tively normal life that does not require the high- compartment is measured. Usually, a rat exhibits cost behaviors (e.g., crime, intravenous injection) some preference for one or the other side in these associated with abuse of illicit opioids. trials. At this point, the experimenter can do one of The animal models described here, particularly two things—(1) modify the compartments in some drug self-administration and drug discrimination, way, perhaps by changing the lighting, so that are now being applied to the development of drugs equal time is spent in the two chambers before that may be useful in treatment. These approaches proceeding (balanced procedure), or (2) go ahead are based on the reasonable but as yet unvalidated with the experiment with unequal preferences (un- assumption that blocking or mimicking the rein- balanced procedure). With either procedure, con- forcing and subjective effects of drugs will decrease ditioning trials are conducted next. drug abuse. In the case of cocaine, dopamine an- To run conditioning trials, a barrier is placed in tagonists and, surprisingly, opioids have shown the middle of the chamber that does not allow the some promise in animal models as potential treat- animal to switch sides. The drug of interest is then ment compounds. It is not yet clear whether these administered to the animal and it is confined to one compounds will be effective in humans. Neverthe- compartment for usually fifteen to thirty minutes. less, this is an area of active research that shows If the unbalanced procedure is used, the animal is promise for helping with treatment of drug abuse usually placed in the compartment that was ini- for development as treatment compounds. tially avoided. A second group may be given a placebo (a substance that has no effect) under these same conditions or a placebo may be given to these (SEE ALSO: Abuse Liability of Drugs; Reinforce- ment; Research) same animals before placing them in the second compartment in alternating sessions. In this way, the effect of the drug is associated with a particular BIBLIOGRAPHY environment. After several—three to ten— BRADY,J.V.,&LUKAS, S. E. (1984). Testing drugs for conditioning sessions, the animal is placed in the physical dependence potential and abuse liability. chamber without being given the drug, and the NIDA research monograph 52. Washington, DC: U.S. door is removed so that the animal can spend time Government Printing Office. in either compartment. The length of time spent in COLPAERT, F. C., & BALSTER, R. L. (1988). Transduction each chamber is recorded and used as a measure of mechanisms of drug stimuli. Berlin: Springer-Verlag. preference for that chamber. WOOLVERTON, W. L., & NADER, M. N. (1990). Experi- The hypothesis underlying this sort of experimental evaluation of the reinforcing effects of drugs. ment is that the length of time spent in an environ- In Testing and evaluation of drugs of abuse. New ment should increase if that environment is associ- York: Alan R. Liss. ated with the effects of a drug of abuse. In fact, many studies have shown that this does happen WILLIAM WOOLVERTON with drugs such as HEROIN,COCAINE, and AMPHET- AMINES. In the balanced procedure, animals spend more time in the drug-associated side than in the Conditioned Place Preference A other side. In the unbalanced procedure, the ani- procedure called conditioned place preference has mals spend more time in the drug-associated side been used to study the ‘‘rewarding’’ effects of than they did previously, but only rarely demon- drugs. The procedure is designed to ask the ques- strate an actual preference for it. As would be ex- tion ‘‘When given a choice, will an animal prefer an pected, preference is greater with higher doses of environment in which it has experienced a drug to the drug and does not occur with placebo injec- one in which it has not?’’ To answer this question, tions. In addition, it does not occur with drugs that an animal is placed in an experimental chamber are not typically abused, such as antipsychotic that is divided into two compartments that are dif- drugs, antidepressant drugs, and opioid antago- ferent in some way. For example, they may have nists. Thus, it seems likely that the technique mea- different floors and/or distinctive odors. Initially, sures a drug effect that is related to drug abuse. the animal is placed in the chamber for several Like other models for studying drug abuse, con- preconditioning trials and the time spent in each ditioned place preference has strengths and weak- RESEARCH, ANIMAL MODEL: Conditioned Withdrawal 991 nesses. Among its strengths is that animals are Conditioned Withdrawal Upon cessation tested in a drug-free state. Therefore, the measure from drug taking, many individuals experience un- of preference is not influenced by the direct effects pleasant effects (i.e., WITHDRAWAL), which can in- of drugs. The procedure can be done with drug clude both physiological and psychological symp- injections given by routes other than intravenous, toms. For example, for OPIATE drugs such as therefore surgical preparation is not involved. MORPHINE and HEROIN, withdrawal symptoms can include restlessness, anorexia, gooseflesh, irritabil- Moreover, the procedure is rapid, with maximum ity, nausea, and vomiting. Withdrawal symptoms effect usually evident within three conditioning ses- are most pronounced following a long history of sions. exposure to ALCOHOL and opiates, but a variety of The major weakness relates to the drug effects withdrawal symptoms can occur after exposure to that it is measuring. Since drug administration is most psychoactive drugs. not due to the behavior of the animal (i.e., self- As with most other drug effects, researchers have administration), it is by definition not a reinforcing shown that these withdrawal symptoms can be con- effect. Although many of the same drugs that are ditioned or linked by learning to environmental self-administered induce place preferences, it is not cues. This research on conditioned withdrawal has clear whether the drug effect studied in conditioned included both human case reports and laboratory place preference is the same as that studied in pro- animal research. For example, Vaillant (1969) re- cedures that directly measure reinforcing effects. ported that individuals who had been abstinent from opiates for months would experience ‘‘acute Another weakness is that is it not known whether it craving and withdrawal symptoms’’ upon reexpo- is meaningful to compare drugs in terms of their sure to situations previously associated with opiate ability to engender place preferences. That is, if use. Further, Goldberg and Schuster (1967) drug X induces a greater place preference than showed that withdrawal symptoms also can be con- drug Y, does it have more abuse potential? Finally, ditioned in laboratory animals. In their experiment, because the procedure involves the simple behav- rhesus monkeys were addicted to morphine by giv- ioral response of moving from one chamber to an- ing them the drug repeatedly. The monkeys were other, it is not known whether it can be used to then given an occasional injection of nalorphine, an study some of the complex behavioral variables opiate antagonist, which immediately led to the that are known to be determinants of drug self- monkeys exhibiting signs characteristic of with- administration. Despite these ambiguities, how- drawal. The injection of nalorphine was always ever, the simplicity of the procedure makes it likely given in the presence of a specific environmental that it will continue to be useful for studying drug stimulus, in this case a tone. Following several exposures to the tone paired with nalorphine, Gold- abuse. berg and Schuster found that presentation of the tone itself was sufficient to produce the withdrawal (SEE ALSO: Abuse Liability of Drugs; Reinforce- signs. ment) The behavioral mechanism most likely to account for the phenomenon of conditioned withdrawal is classical conditioning (also known as BIBLIOGRAPHY Pavlovian). In Pavlov’s classic experiments on this BOZARTH, M. A. (1987). Conditioned place preference: A type of conditioning, a neutral stimulus such as a parametric analysis using systemic heroin injections. bell, is repeatedly paired with a nonneutral stimu- In Methods of assessing the reinforcing properties of lus such as food. Eventually the bell itself elicited abused drugs, pp. 241–273. New York. Springer- salivation, which was initially observed only to the Verlag. food. In conditioned withdrawal, a neutral stimulus (e.g., a bell, a needle, a room, a friend, a street HOFFMAN, D. C. (1989). The use of place conditioning in corner, or certain smells) is paired with the non- studying the neuropharmacology of drug reinforce- neutral stimulus of withdrawal until eventually ment. Brain Research Bulletin, 23, 373–387. those neutral stimuli will also elicit withdrawal WILLIAM WOOLVERTON symptoms. 992 RESEARCH, ANIMAL MODEL: Drug Discrimination Studies

The phenomenon of conditioned withdrawal can ministering drugs, usually morphine-like drugs, to have important implications for drug-abuse treat- former HEROIN addicts—who then answered ques- ment. The experience of drug withdrawal is often tionnaires that were designed to detect and classify an important factor in the long-term maintenance the subjective effects of the drug. The single-dose of drug abuse. That is, as individuals experience OPIATE questionnaire asks subjects whether they withdrawal, they are likely to seek out a new drug can feel the drug, to identify the drug, to describe supply to relieve withdrawal symptoms. An impor- the symptoms, and to rate how much they like it. tant aspect of drug-abuse treatment is relieving the The Addiction Research Center Inventory consists symptoms of withdrawal during the period imme- of a series of true/false statements that describe diately following the cessation of drug use. Condi- internal states that might be produced by drugs. tioned effects, however, are often long-lasting and The Profile of Mood States is a list of adjectives that do not depend on the continued presentation of the can be used to describe mood. Responses to these initial nonneutral stimulus (in this case with- questionnaires depend on variables such as type of drawal). Even after a patient has been withdrawn drug and drug dose. Recent research has examined from a drug, stimuli that have been conditioned to the subjective effects of a wider variety of drugs elicit withdrawal symptoms may still be effective. (including STIMULANTS and DEPRESSANTS) in both Therefore, upon reexposure to those stimuli a pa- experienced and inexperienced subjects. The pur- tient may be much more likely to relapse to drug pose of this research is to understand the factors abuse. Thus, to be successful, any treatment regi- that can influence a person’s subjective response to men for drug abuse must deal with conditioned drugs of abuse. withdrawal. Since subjective effects require a verbal description of an internal state, they can only be studied directly in humans. Since the 1960s, however, it (SEE ALSO: Causes of Substance Abuse; Wekler’s has become clear that animals can be trained to Pharmacologic Theory of Drug Addiction) respond in a way that suggests they can detect the internal state produced by a drug. The behavioral BIBLIOGRAPHY paradigm is called DRUG DISCRIMINATION, and the GOLDBERG, S. R., & SCHUSTER, C. R. (1967). Condi- drug effect is called a discriminative stimulus effect. tioned suppression by a stimulus associated with Although a number of drug-discrimination para- nalorphine in morphine-dependent monkeys. Journal digms have been developed, the most common is a of the Experimental Analysis of Behavior, 10, 235– two-lever paradigm. Here the animal is trained to 242. press one lever after it has received a drug injection VAILLANT, G. E. (1969). The natural history of urban and the second lever after an injection of the drug narcotic drug addiction—Some determinants. In H. vehicle or, in some cases, another drug. Responding Steinburg (Ed.), Scientific basis of drug dependence. on the lever that is appropriate to the injection is New York: Grune & Stratton. reinforced, usually, by a food pellet; responding on the incorrect lever is not reinforced. If this is done CHARLES SCHINDLER repeatedly over a period of several weeks, the ani- STEVEN GOLDBERG mal learns to respond almost exclusively on the lever associated with the injection. Although it is difficult to know what an animal Drug Discrimination Studies When a feels, it seems as if the animal is telling us whether it person takes a drug of abuse, it has effects that a feels the drug or not by the lever it presses. The person feels and can describe. These are termed animal can then be asked to ‘‘tell’’ us whether a subjective effects and they play an important role in new drug ‘‘feels’’ like the training drug. It will re- drug abuse. People are more likely to abuse a drug spond on the drug lever if it does and on the vehicle that has effects they describe as pleasant than one lever if it does not. It can also be ‘‘asked’’ whether a they describe as unpleasant. drug blocks the effects of the training drug. If the The subjective effects of drugs of abuse have test drug does block the effect of the training drug, been studied in humans for many years and in the animal will respond on the vehicle lever when several different ways. Early research involved ad- given both drugs. RESEARCH, ANIMAL MODEL: Drug Self-Administration 993

CONCLUSIONS Techniques developed on laboratory animals allow us to study the reinforcing effects of drugs, What makes this area of research so exciting are using the intravenous and oral routes as well as the striking similarities between the classification of smoking. To study intravenous self-administration, drugs by humans, based on their subjective effects, the researcher surgically implants a chronic intra- to those by animals, based on their discriminative venous line (a catheter) through which a drug can stimulus effects. Therefore, this animal model can be administered. Laboratory animals (rats, mice, be used to investigate the influence of factors such monkeys, and so on) live in cages in which they can as genetics, drug history, and behavioral history— operate some device, usually a lever press, that factors that cannot be easily controlled in human turns on an electric pump to send some drug solu- subjects—on the subjective effects of drugs. It also tion through the catheter. Oral self-administration allows us to predict whether a new drug is likely to is harder to establish, since drugs are usually bitter; have subjective effects, like a known drug of abuse, however, by arranging conditions so that large or is likely to block the subjective effects of the drug amounts of drug solution are ingested in relatively of abuse, without giving the drug to humans. If an short periods—usually by adding the drug to water animal is trained to discriminate a drug of abuse when food is available—researchers can condition and presses the drug lever when given the new animals to self-administer drugs orally. Research drug, then it is highly likely that the new drug will on the smoking of TOBACCO or CRACK-COCAINE is have subjective effects in humans similar to those important and this too needs conditioning for reli- of the drug of abuse. Its availability might then be able study. restricted. If the animal responds on the vehicle Animals used in research studies have shown lever when given the combination of the new drug that, with few exceptions, they abuse the same and the drug of abuse, the new drug may block the drugs that humans abuse and show similar patterns subjective effects of the drug of abuse. Such a drug of intake. (Exceptions include MARIJUANA and might then be useful for treating drug abuse. HALLUCINOGENS, such as LSD, which animals do not seem to find reinforcing.) Drug self-administra- (SEE ALSO: Abuse Liability of Drugs; Drug Types; tion studies have been used to predict whether a Sensation and Perception) new drug is likely to be abused by humans if it becomes easily available. More important, such re- BIBLIOGRAPHY search has allowed us to understand some factors that can increase or decrease the reinforcing effects COLPAERT, F. C. (1986). Drug discrimination: Behav- of drugs that contribute to human drug abuse. ioral, pharmacological, and molecular mechanisms of Some of these factors relate to the drug itself; others discriminative drug effects. In Behavioral analysis of to the environment. For example, drugs that in- drug dependence. Orlando, FL: Academic. crease the concentration of the NEUROTRANSMITTER COLPAERT, F. C., & BALSTER, R. L. (1988). Transduction DOPAMINE in the synapses of the brain (e.g., co- mechanisms of drug stimuli. Berlin: Springer-Verlag. caine) are more likely to have abuse potential than WILLIAM WOOLVERTON those that do not. Research has made it clear that even the most preferred drug—cocaine—will be self-adminis- Drug Self-Administration One factor that tered differently depending on environmental con- distinguishes a drug of abuse from a drug that is ditions. If more lever presses are required to obtain not abused is that taking the drug of abuse in- it (it ‘‘costs’’ more), less is consumed. Drug self- creases the likelihood that it will be taken again. In administration can also be decreased by punish- such a case, we say that this drug has reinforced the ment or by making valuable alternatives available. drug self-administration response and that it has In short, drug self-administration research has reinforcing effects. Factors that influence reinforc- shown that whether a drug will be abused is deter- ing effects, therefore, profoundly influence drug mined by a complex interaction between the drug, self-administration and drug abuse. Knowing the the environment, and the organism. Current re- reinforcing effects of drugs is essential to under- search is aimed at understanding the dynamics of standing drug abuse. that interaction in a quantitative way. 994 RESEARCH, ANIMAL MODEL: Environmental Influences on Drug Effects

(SEE ALSO: Abuse Liability of Drugs; Adjunctive differential effects of the drugs could not be based Drug Testing) on different levels of motivation, since these sched- WILLIAM WOOLVERTON ule conditions alternated sequentially within the same experimental session. Although these and similar results were obtained under carefully controlled experimental conditions, such findings doc- Environmental Influences on Drug Ef- ument the essential point that environmental con- fects More than any other discipline, the field of ditions surrounding and/or supporting behavior behavioral PHARMACOLOGY has attempted to un- play a very important role in determining the ef- derstand the influence of nonpharmacological, or fects of drugs. environmental, factors on the effects of abused drugs. Since the classic demonstration by Dews (1955, 1958) showing that the effects of pentobar- BEHAVIORAL CONTEXT bital and METHAMPHETAMINE depend on the man- The environmental modulation of drug effects ner in which behavior is controlled by the schedule has been shown repeatedly, by using schedule-con- of REINFORCEMENT, researchers have been interes- trolled responses and various types of events. These ted in various environmental influences on the ef- findings represent two areas of research demon- fects of drugs. Some of these effects are described strating how drug effects are modified directly by elsewhere in this encyclopedia (and see Barrett, existing environmental conditions: 1987, for a more detailed review). This article reviews additional influences to illustrate the over- (1) More remote influences can also influence drug whelming conclusion that the effects of a drug de- action. In behavioral history, for example, con- pend on complex environmental variables that may sequences that have occurred in the distant override the typical pharmacological effects of a past can significantly alter the effects of abused compound. Indeed, the evidence for environmental drugs even though no traces of that experience influences on drug action is so compelling that are apparent in current behavior. when the effects of abused drugs are characterized, (2) In other studies in which environmental influ- ‘‘susceptible to environmental modulation’’ should ences helped determine the effects of an abused be a salient distinguishing description along with drug, behavioral consequences occurring un- physiological features. der one experimental condition alter the action of drugs occurring under different conditions. BEHAVIORAL CONSEQUENCES In this case, the conditions that interact are relatively close in time. For example, in an ex- The specific manner in which behavior is con- periment with monkeys, exposure to a proce- trolled by its consequences may often represent a dure in which responses avoided the delivery of strong influence on drug action. In research situa- a mild electric shock completely reversed the tions, this is apparent in the effects of AMPHET- effects of amphetamine on punished responses AMINE or COCAINE on punished and nonpunished that had occurred in a different and adjacent responses maintained by the presentation of food. context (i.e., under different stimulus condi- Low rates of nonpunished responses are typically tions from the avoidance schedule and sepa- increased by these drugs (PSYCHOMOTOR STIMU- rated by only a few minutes). LANTS), whereas comparable low rates on punished responses are not affected by these drugs or are Comparable results, although with different only decreased further. In the Dews studies (1955, species, different schedule conditions, and differ- 1958), the effects of the drugs differed depending ent environmental events, have also been arrived on whether behavior was maintained at relatively at with ALCOHOL, cocaine, and CHLORDIAZE- high response rates under a fixed-ratio schedule POXIDE (Barrett, 1987). The findings show the that provided food following every nth response or generality of this phenomenon—that the environ- whether responses occurred at lower rates under a ment is an important variable contributing to the fixed-interval schedule that provided food for the effects of drugs on behavior. The actions of a first response after t minutes. Explanations of the drug at its receptor site and the transduction RESEARCH, ANIMAL MODEL: Intracranial Self-Stimulation (ICSS) 995 mechanisms that ensue can be affected by events electrical impulses was implanted in the brain of a occurring in the environment. rat. These animals could be trained to press a lever that would activate the implanted electrode, send- SUMMARY ing a small impulse to a specific brain region. In addition, animals could also be trained to press a The studies described here indicate the powerful lever that would ‘‘shut off’’ brain impulses in other influences that exist in the environment that can regions. These animals will give up food and water, alter the course of the effects of abused drugs. Such and even sexual activities, in order to perform tasks findings illustrate the need to examine those influ- that lead to brain stimulation in certain regions. ences and the manner in which they occur, al- Based on these results, this procedure was recog- though it is often tempting to attribute all changes nized as a method by which mechanisms under- in behavior to the abused drug. Consequences that lying drug addiction could be studied. are immediate, as in the existing environment, or Early work in brain stimulation involved remote, such as in the individual’s past experience, mapping out which brain areas would support self- help determine the acute effects of drugs and may stimulation in animals, primarily rats. Animals also contribute to long-term abuse and persistent were trained using operant procedures in which a drug use. press of the lever would deliver an electrical stimulus to the brain. Researchers found two systems of (SEE ALSO: Adjunctive Drug Taking; Causes of Sub- reward in the rat brain using ICSS: a dorsal (closer stance Abuse; Reward Pathways and Drugs; Toler- to the back of the animal) system projecting from ance and Physical Dependence) the caudate/septal area through the dorsal thala- mus to the tectum, and a ventral system (closer to BIBLIOGRAPHY the abdomen of the animal), the medial forebrain bundle. The ‘‘punishment’’ system seemed to be BARRETT, J. E. (1987). Nonpharmacological factors de- located in the diencephalon and the tegmentum. termining the behavioral effects of drugs. In H. Y. Rats will readily self-stimulate when electrodes are Meltzer (Ed.), Psychopharmacology: The third gener- implanted into the ventral tegmental area (VTA) ation of progress. New York: Raven Press. and substantia nigra, brain regions associated with DEWS, P. B. (1958). Studies on behavior: IV. Stimulant reward. Researchers hypothesized that, by stimu- actions of methamphetamine. Journal of Pharmacol- lating these brain regions, the rats were activating ogy and Experimental Therapeutics, 122, 137–147. their own dopamine neurons electrically, thus pro- DEWS, P. B. (1955). Studies on behavior: I. Differential ducing the effects of reward. Dopamine is a neuro- sensitivity to pentobarbital of pecking performance in transmitter found in the brain of rodents and pri- pigeons depending on the schedule of reward. Journal mates. This neurotransmitter is thought to be of Pharmacology and Experimental Therapeutics, involved in the rewarding or pleasurable effects of 113, 393–401. drugs of abuse. JAMES E. BARRETT Drugs can interact with the established pattern of self-stimulation in an animal. Interactions between drugs and ICSS suggest that these treatments Intracranial Self-Stimulation (ICSS) act through the same mechanisms. The rate at The intracranial self-stimulation (ICSS) procedure which the animal presses the lever is correlated is used to study the effects of drugs on reward with the intensity of the current being delivered to processes, or regions involved in pleasurable feel- the brain. However, the rate at which the animal ings, in the brain. In humans undergoing brain presses the lever is not necessarily related to the surgery, researchers were able to induce limb amount of pleasure the animal is experiencing. The movements or produce sensations by electrically influences of various drugs on self-stimulation be- stimulating various regions of the cortex. Similarly, havior can be due to a variety of effects, such as electrical stimulation of certain brain regions in the increases or decreases in general activity, changes rat was reinforcing, or pleasurable, thus creating a in motivation or memory, etc. To state that a drug new area for brain research. An electrode capable has an effect on self-stimulation, these possibilities of delivering varying intensities and durations of must be ruled out. To do this, one can compare 996 RESEARCH, ANIMAL MODEL: Learning, Conditioning, and Drug Effects—An Overview data describing the effects of the test drug in other have been observed. When low doses of cocaine behavioral paradigms (e.g., locomotor activity, were given once or several times a day, no changes self-administration) to the effects observed in ICSS. in the ICSS threshold were observed. However, Despite these limitations, researchers have col- when higher doses of cocaine were administered for lected interesting data, examining the effects of seven days, the reward threshold was increased in various drugs of abuse on rate of self-stimulation. these animals, indicating that tolerance to the re- Animals were trained to press a lever that would warding effect of cocaine had developed and/or result in electrical stimulation of the brain. Then, that the effects of cocaine had become less pleasur- the intensity of the stimulation was lowered so that able. In addition, animals that self-administered the animals would not press the lever very often. cocaine also exhibited this increase in the ICSS When the animals were given the psychomotor reward threshold. These experimental results are stimulant amphetamine, the animals began to press comparable with those observed in human drug the lever at a very high rate that gradually declined users who take increasingly greater amounts of to the rate observed at low stimulation intensities. drug to achieve the same pleasurable effect over a To rule out that animals might be pressing the lever long period of time. more often due to the motor-activating effects of amphetamine, these researchers looked at the ef- BIBLIOGRAPHY fects of amphetamine on lever-pressing in rats that were not receiving any brain stimulation. They saw GREENSHAW, A., & WISHART, T. (1987). Effects of drugs no changes in lever-pressing before or after the rats on reward processes. In A. Greenshaw & C. Dourish, were given amphetamine. Thus, they concluded (Eds.), Experimental psychopharmacology: Concepts that amphetamine enhances the reward produced and methods. Clifton, NJ: Humana Press. by the subthreshold stimulation by activating re- HAMMER, R., EGILMEZ, Y., & EMMETT-OGLESBY,M. ward pathways in the brain. (1997). Neural mechanisms of tolerance to the effects Another approach in using ICSS to measure the of cocaine. Behavioral Brain Research, 84, 225–239. rewarding effects of drugs is to train animals to SILVERMAN, P. (1978). Animal behaviour in the labora- regulate the intensity of the stimulation that they tory. New York: Pica Press. receive in the brain. Animals are given access to two HEATHER L. KIMMEL levers in the test chamber. When the animal pressed one of these levers for the first time, a relatively high level of brain stimulation was delivered. However, subsequent presses of the lever Learning, Conditioning, and Drug Ef- deliver decreasing levels of stimulation. The animal fects—An Overview The effects of abused can ‘‘reset’’ the stimulation to the original high drugs can be examined at many levels, ranging level by pressing the second lever. Under these con- from the molecular to the cellular to the behavioral. ditions, the animals reliably reset their stimulation Each of these research areas contributes significant level once it drops below a certain point. From this information to understanding the mechanisms by measurement, researchers are able to determine which drugs of abuse and alcohol produce their each animal’s reward threshold in a very reliable diverse effects. The most tangible sign of both im- way. Regardless of the initial level of stimulation, mediate and long-term actions of abused drugs is these animals would press the reset lever at the their effects on behavior. Often it is incorrectly as- same intensity of stimulation. Drugs such as am- sumed that behavior is a passive reflection of more phetamine and morphine have ‘‘threshold-lower- significant events occurring at a different and (usu- ing’’ effects, such that the animals would press the ally) more molecular level. Understanding those reset lever at a lower intensity after receiving these cellular events is occasionally viewed as the key to drugs. This suggests that these drugs are them- understanding drug abuse and to intervention selves reinforcing, or pleasurable. strategies. In fact, however, behavior itself and the ICSS has been used to study the effects of the variables that control it play a prominent and often chronic administration of cocaine. Depending on profound role in directly determining drug action the frequency of administration and amount of and, most likely, those cellular and molecular cocaine given, difference changes in ICSS responses events that participate in behavior and in the ef- RESEARCH, ANIMAL MODEL: Learning, Conditioning, and Drug Effects—An Overview 997 fects of drugs. The variables that guide and influ- experimental research using operant conditioning ence behavior also affect molecular substruc- techniques to study the effects of abused drugs is tures—therefore, behavioral and neurobiological extensive (see Iversen & Lattal, 1991, for general processes are interdependent. reviews of the techniques and applications). Unconditioned and Conditioned Respon- EXPERIMENTAL ANALYSIS OF dent Behavior. Respondent behavior is elicited BEHAVIOR AND DRUGS OF ABUSE by specific stimuli and usually involves no specific training or conditioning, since the responses stud- The progression of behavioral approaches in the ied are typically part of the behavioral repertoire of study of the effects of abused drugs is characteristic the species and are expressed under suitable envi- of the cumulative and evolutionary nature of scien- ronmental conditions. Although the factors respon- tific progress. A number of techniques are now sible for the occurrence of these behaviors presum- available that permit the development and mainte- ably lie in the organism’s distant evolutionary past, nance of a variety of behaviors that are remarkably certain unconditioned responses can be brought stable over time, sensitive to a number of interven- under more direct and immediate experimental tions, and reproducible within and across species. control through the use of procedures first discov- These procedures have evolved over the past sev- ered and systematically explored by Pavlov. These eral years and reflect the combined efforts of indi- procedures consist of expanding the range of stim- viduals in different disciplines ranging from psy- uli capable of producing an elicited response. In chology, pharmacology, physiology, and ethology. respondent conditioning, previously noneffective For the most part, research studying the effects of stimuli acquire the ability to produce or elicit a abused drugs on behavior has been conducted by response by virtue of their temporal association two basic procedures. One procedure uses uncondi- with an unconditional stimulus, such as food, tioned behavior, such as locomotor activity that is which is capable of eliciting a response without more spontaneous in its occurrence (but still influ- prior conditioning. Thus, when a distinctive noise, enced by environmental conditions) and requires such as a tone, is repeatedly presented at the same no specific training before it can be studied. Many time that or shortly before food is given, the tone PSYCHOMOTOR STIMULANTS such as COCAINE and acquires the ability to elicit many of the same re- AMPHETAMINE, for example, produce large and sponses originally limited to food. consistent increases in locomotor activity in labora- Respondent behaviors depend primarily on an- tory animals. Frequently, however, unconditioned tecedent events that elicit specific responses. Typi- behavior is produced or elicited by the presentation cally, these responses do not undergo progressive of specific stimuli, and it is then brought under differentiation, that is, the responses to either a experimental control by arranging for the produc- conditioned or an unconditioned stimulus are gen- tion of a response to a stimulus other than that erally quite similar. These procedures also do not originally responsible for its occurrence. The Rus- establish new responses but simply expand the sian physiologist Ivan Pavlov, for example, per- range of stimuli to which that response occurs. formed extensive studies in 1927, in which he used Operant Behavior. In contrast to respondent the unconditioned salivary response to food and to behavior, operant behavior is controlled by conse- conditioned stimuli paired with food to study pro- quent events, that is, it is established, maintained, cesses of classical or respondent conditioning. Al- and further modified by its consequences. Operant though this approach has been used somewhat less behavior occurs for reasons that are not always often than other techniques, respondent condition- known. The responses may have some initially low ing procedures still serves as a very useful method probability of occurrence or they may never have for studying drug action (Barrett & Vanover, occurred previously. Novel or new responses are 1993). typically established by the technique of ‘‘shap- The second procedure, which is designated as ing,’’ in which a behavior resembling or approxi- operant conditioning, uses the methods and tech- mating some final desired form or characteristic is niques developed by the pioneering American psy- selected, increased in frequency and then further chologist B. F. Skinner (1938) to investigate be- differentiated by the provision of a suitable conse- havior controlled by its consequences. The body of quence, such as food presentation to a food-de- 998 RESEARCH, ANIMAL MODEL: Learning, Conditioning, and Drug Effects—An Overview prived organism. This technique embodies the conditions, however, the response remains essen- principle of reinforcement and has been widely tially the same. used to develop operant responses such as lever In contrast, operant behavior depends to a large pressing by rodents, humans, and nonhuman pri- extent on its consequences, and with this process, mates. Behavior that has evolved under such con- complex behavior can develop from quite simple tingencies may bear little or no resemblance to its relationships. One has only to view current behav- original form and can perhaps only be understood ior as an instance of the organism’s previous history by careful examination of the organism’s history. acting together with more immediate environmen- Although some behaviors often appear unique or tal consequences to gain some appreciation for the novel, it is likely that the final product emerged as a continuity and modification of behavior in time. continuous process directly and sequentially re- Current behavior is often exceedingly difficult to lated to earlier conditions. The manner in which understand because of the many prior influences or operant responses have been developed and main- consequences that no longer operate but which may tained, as well as further modified, has been the leave residual effects. The effects of a particular subject of extensive study in the behavioral phar- consequence or intervention can be quite different macology of abused drugs and has had a tremen- depending on the behavior that exists at the time dous impact on this field. Many of the potent vari- the event occurs. An individual’s prior history, ables that influence behavior, such as then, is important not only because it has shaped reinforcement, punishment, and precise schedules present behavior but also because it will undoubt- under which these events occur, also are of critical edly determine the specific ways in which the indi- import in determining how a drug will affect vidual responds to the current environment. Ac- behavior. cordingly, prior behavioral experience can have a Respondent Versus Operant Behavior. marked effect in determining how a drug will Although it is possible to tell operant behavior from change behavior. respondent behavior in a number of ways, these processes occur concurrently and blend almost in- BEHAVIORAL METHODOLOGY AND distinguishably. For example, the administration of THE EVALUATION OF ABUSED DRUGS a drug may elicit certain behavioral and physiologi- Experiments with drugs and behavior were initi- cal responses such as increased heart rate and ated in Pavlov’s laboratory in Russia during the changes in perception that are respondent in na- time that Pavlov was studying the development of ture; stimuli associated with the administration of conditioned respondent procedures (see Laties, that drug may also acquire some of the same ability 1979, for a review of this early work). Early experi- to elicit those responses. If the administration of the ments with the effects of drugs on operant behavior drug followed a response and if the subsequent were initiated shortly after Skinner began his pio- frequency of that response increased, then the drug neering work (Skinner & Heron, 1937). More in- also could be designated a reinforcer of the operant tensive studies using drugs and operant-condition- response. Thus, these important behavioral pro- ing techniques were not conducted, however, until cesses frequently occur simultaneously and must be effective drugs for the treatment of various psychi- considered carefully in experimental research, and atric disorders such as SCHIZOPHRENIA were intro- also in attempting to understand the control of duced in the 1950s. These discoveries prompted behavior by abused drugs. The primary distinc- the development and extension of behavioral tech- tions between operant and respondent behavior niques to study these drugs, and many of the proce- now appear to be the way these behaviors are pro- dures were subsequently used in the study of duced and the possible differential susceptibility to abused drugs. From these combined efforts, several modification by consequent events. Respondent be- key principles evolved that have served as the foun- havior is produced by the presentation of eliciting dation for understanding and evaluating the effects stimuli; characteristic features of these behaviors of abused drugs. are rather easily changed by altering the features of Environmental Events. As already discussed, the eliciting stimulus such as its intensity, duration, behavior can be controlled by a wide range of or frequency of presentation. Under all of these environmental events. One question that arose RESEARCH, ANIMAL MODEL: Learning, Conditioning, and Drug Effects—An Overview 999 early in the study of the behavioral effects of drugs ance and lethality (Siegel, 1983). These studies add was whether the type of environmental event that to the rather convincing body of evidence that envi- controlled behavior contributed to the effects of a ronmental conditions accompanying the adminis- drug—that is, whether a behavior controlled by a tration and effects of the drug can be of consider- positive event, such as food presentation, would be able importance in determining the effects of that affected in the same manner as a behavior con- drug when it is administered, as well as when it is trolled by a more negative event, such as escape subsequently administered. from an unpleasant noise or bright light. Although Behavioral and Pharmacological History. seemingly straightforward, the issue is not easily In addition to pointing to the contribution of the addressed because other known factors contribute immediate environment in determining the effects to the actions of drugs, such as the rate at which a of abused drugs, a number of studies demonstrated behavior controlled by the event occurs. If rates are that the consequences of past behavior could also not similar, any comparison between drug effects contribute significantly to the effects of drugs, often on behavior controlled by those different events by resulting in an action that is completely opposite might be spurious. Indeed, when such comparisons to that shown in organisms without that history. have been conducted in nonhuman primates under These findings convey the complexity involved in carefully controlled conditions, it has been shown understanding the effects of drugs of abuse, and the that the type of environmental event controlling difficulties in attempting to understand their ac- behavior can play an important role in determining tions in humans with more complex life histories the qualitative effects of a drug on behavior than those of experimental animals. In addition, (Barrett & Witkin, 1986; Nader, Tatham, & related studies showed that prior experience with Barrett, 1992). For example, when the effects of one drug could also directly affect the manner in certain drugs such as ALCOHOL or MORPHINE were which behavior is influenced by other drugs. studied by using behavioral responses of monkeys Early studies using different training conditions who were similarly maintained by a food stimulus to develop a visual discrimination in pigeons dem- or a mild electric-shock stimulus, the drugs pro- onstrated that an antipsychotic drug, Thorazine duced different effects depending on the maintain- (chlorpromazine), and an antidepressant drug, ing event (Barrett & Katz, 1981). These findings imipramine, had different effects on that discrimi- suggest that the manner in which behavior is con- native behavior, depending on how the training trolled by its environmental consequences—that is, occurred (Terrace, 1963). Similarly, studies that the characteristics of the environment—can be of used exploratory behavior of rats in mazes demon- considerable importance in determining how an in- strated that the effects of a mixture of amphet- dividual will be affected by a particular drug. This amine (STIMULANT) and a BARBITURATE drug was one of the experiments that supported the view (DEPRESSANT) depended on whether the rats had that a drug is not a static molecule with uniform been previously exposed to the maze (Steinberg, effects, but rather that the way the substance inter- Rushton, & Tinson, 1961). More recently, studies acts with its receptor and initiates the cascade of with squirrel monkeys showed that prior behav- biochemical processes depends very much on the ioral experience can influence the effects of a wide dynamic interaction of behavior within its environ- range of drugs, including morphine, cocaine, and ment. When the issue is viewed in this light, it is amphetamine, as well as alcohol, under a variety of clear that environmental events and the way they experimental conditions (summarized by Barrett, impinge on behavior contribute substantially to the Glowa, & Nader, 1989; Nader et al., 1992). In one specific effects of a drug and its impact on the study, for example, the effects of amphetamine individual organism. were studied on behavior reinforced by food that Examples of similar types of environmental con- was also suppressed by punishment. Under these trol over pharmacological effects of drugs also conditions, amphetamine produced a further de- come from studies that employed respondent con- crease in punished responding. If those same mon- ditioning procedures to demonstrate that stimuli keys, however, were then exposed to a procedure in paired with morphine or heroin injections can in- which responding postponed or avoided punishing fluence the development and manifestation of fun- shock and were then returned to the punishment damental pharmacological processes such as toler- condition, amphetamine no longer decreased re- 1000 RESEARCH, ANIMAL MODEL: Learning, Conditioning, and Drug Effects—An Overview

sponding; instead, it produced large increases in BIBLIOGRAPHY suppressed responding. Thus, the effects of am- BARRETT, J. E., GLOWA, J. R., & NADER, M. A. (1989). phetamine in this study depended on the prior be- Behavioral and pharmacological history as determi- havioral experience of the animal. nants of tolerance- and sensitization-like phenomena These findings raise a number of issues sur- in drug action. In M. S. Emmett-Oglesby & A. J. rounding the etiology of drug abuse as well as issues Goudie (Eds.), Tolerance and sensitization to psycho- pertaining to an individual’s risk for or vulnerabil- active agents: An interdisciplinary approach. Clifton, ity to abusing particular drugs. If, as seems likely, NJ: Humana Press. certain drugs are abused because of their effects on BARRETT, J. E., & KATZ, J. L. (1981). Drug effects on behavior, and those behavioral effects are related to behaviors maintained by different events. In T. past history, then the historical variables become Thompson, P. B. Dews, & W. A. McKim (Eds.), Ad- exceptionally important in eventually understand- vances in behavioral pharmacology (Vol. 3). New ing and treating, as well as preventing, drug abuse. York: Academic Press. Perhaps previous behavioral experience generates BARRETT, J. E., & VANOVER, K. E. (1993). 5-HT recep- conditions under which a drug may have quite tors as targets for the development of novel anxiolytic powerful actions on behavior and on the subjective drugs: Models, mechanisms and future directions. effects that drug produces; by virtue of their previ- Psychopharmacology, 112, 1–12. ous history, the susceptible individuals may be pre- BARRETT, J. E., & WITKIN, J. M. (1986). The role of disposed to drug abuse. If these arguments are behavioral and pharmacological history in determin- valid, it should be possible, after achieving a better ing the effects of abused drugs. In S. R. Goldberg & understanding of the factors, to develop behavioral I. P. Stolerman (Eds.), Behavioral analysis of drug strategies for ‘‘inoculating’’ or ‘‘immunizing’’ indi- dependence. New York: Academic Press. viduals against particular drug effects. Although FALK, J. L. (1983). Drug dependence: Myth or motive? such possibilities may seem remote at this time, it is Pharmacology Biochemistry and Behavior, 19, 385– very clear that behavioral variables can direct the 391. effects of abused drugs in striking and significant IVERSEN, I. H., & LATTAL, K. A. (1991). Experimental ways. analysis of behavior (Parts 1 and 2). New York: Else- vier. SUMMARY LATIES, V. G. (1979). I. V. Zavodskii and the beginnings Although drugs of abuse have a reliable and of behavioral pharmacology: An historical note and predictable spectrum of effects under a broad range translation. Journal of the Experimental Analysis of of conditions, the implications from studies are that Behavior, 32, 463–472. many of the more characteristic effects of abused NADER, M. A., TATHAM, T. A., & BARRETT, J. E. (1992). drugs can be altered by the organism’s history and Behavioral and pharmacological determinants of drug by the environmental conditions under which the abuse. Annals of the New York Academy of Sciences, drug is and has been administered. As Folk (1983) 654, 368–385. said so eloquently, ‘‘Pharmacological structure PAVLOV, I. (1927). Conditioned reflexes: An investiga- does not imply motivational destiny’’; the reasons tion of the physiological activity of the cerebral cor- for the effects of an abused drug depend on more tex. London: Oxford University Press. than the static molecular properties of that drug. SIEGEL, S. (1983). Classical conditioning, drug toler- Both past and present environmental factors can ance, and drug dependence. In Y. Israel et al. (Eds.), play an overwhelming role in determining the be- Research advances in alcohol and drug problems havioral effects of abused drugs, and they may (Vol. 7). New York: Plenum. indeed be a major source of the momentum behind SKINNER, B. F. (1938). Behavior of organisms. New the continued use and abuse of those substances. York: Appleton-Century-Crofts. SKINNER, B. F., & HERON, W. T. (1937). Effects of caf- (SEE ALSO: Abuse Liability of Drugs; Addiction: feine and benzedrine upon conditioning and extinc- Concepts and Definitions; Adjunctive Drug Taking; tion. Psychological Record, 1, 340–346. Causes of Substance Abuse; Reinforcement; Vulner- STEINBERG, H., RUSHTON, R., & TINSON, C. (1961). Modi- ability as Cause of Substance Abuse) fication of the effects of an amphetamine-barbiturate RESEARCH, ANIMAL MODEL: Learning Modifies Drug Effects 1001

mixture by the past experience of rats. Nature, 192, In some cases, drugs also acquire stimulus con- 533–535. trol over behavior in a procedure known as state- TERRACE, H. S. (1963). Errorless discrimination learning dependent learning. This procedure is different in in the pigeon: Effects of chlorpromazine and imipra- some ways from that used to study drugs as dis- mine. Science, 140, 318–319. criminative stimuli. State-dependent learning re- JAMES E. BARRETT fers to the finding that subjects exposed to a particular procedure when injected with a drug often are impaired upon reexposure to that condition if the drug is not present. Thus, the drug can be viewed as Learning Modifies Drug Effects A part of the original context in which a response was general framework within which to understand the learned. One concern that stems from the finding basic processes and principles of respondent condi- that behavior learned during a drug-related conditioning (as first discovered in the 1920s by Russian tion is impaired in the absence of the drug is that of physiologist Ivan Pavlov [1849–1936] and subse- the potentially enduring problems related to frequently elaborated in many laboratories over the quent abuse of drugs during adolescence—a period next six decades) is described elsewhere. Here, spe- often associated with major developmental and cific examples of the role of conditioned drug effects cognitive growth. are provided in an effort to more fully develop the point that conditioned or learned responses come REINFORCING EFFECTS OF about as a reaction to stimuli that have been associ- DRUG-PAIRED STIMULI ated with drug injections. These stimuli can play a powerful role in governing subsequent behavior in Thus far, the focus has been on the effects of the absence of the drug. environmental stimuli paired with the administration of a drug rather than on stimuli paired with a CONDITIONED EFFECTS OF DRUGS drug as a reinforcer. As has been frequently demonstrated, and as is true of many stimuli, drugs can In addition to studies described previously have multiple functions. These include discrimina- showing that tolerance to the effects of a drug, as tive effects, which set the occasion for certain re- well as lethality, can depend on respondent-condi- sponses to occur, and they also include reinforcing tioning phenomena, a number of additional studies effects, whereby a response is increased in proba- have demonstrated the conditioning of WITH- bility when a reinforcing drug follows the occur- DRAWAL and other responses that are typically as- rence of that response. Drug self-administration sociated only with the presentation or removal of techniques have been very informative and useful the drug. For example, by pairing a tone stimulus in the study of the effects of abused drugs. with the administration of nalorphine, an OPIOID One additional experimental procedure that has ANTAGONIST that precipitates withdrawal signs or been used in this field of research is that of repeat- the abstinence syndrome (agitation, excessive sali- edly pairing a rather brief visual or auditory stimu- vation, and emesis) in morphine-dependent sub- lus (e.g., a light or a tone, respectively) with the jects, it was possible to show in rhesus monkeys reinforcing administration of the drug and then that the tone acquired the ability to elicit with- using that stimulus also as a reinforcer to maintain drawal responses when presented in the absence of behavior without drug administration. Perhaps the natorphine (Goldberg & Schuster, 1967; 1970). most compelling work in this area stems from a Striking illustrations of similar conditioned with- procedure in which a stimulus was presented ac- drawal responses in HEROIN addicts, as well as cording to a schedule to follow a particular re- CRAVING, in which environmental stimuli trigger sponse. On certain occasions, that stimulus also the disposition to self-administer the drug, also was associated with the administration of a drug— have been described. These behavioral responses to that is, the stimulus occurred at various times with- stimuli that have been previously associated with out the drug and then also just preceding the drug. drug withdrawal or administration often occur af- Known technically as a ‘‘second-order schedule,’’ ter a prolonged period of time spent without drugs this technique exerts powerful control over the oc- (O’Brien, 1976). currence and patterning of behavior, and it results 1002 RESEARCH, ANIMAL MODEL: Operant Learning Is Affected by Drugs in sustained responding for extended time periods Operant Learning Is Affected by Drugs in the absence of anything but the stimuli that have According to psychologist B. F. Skinner, behavior been paired with the administration of the drug that is rewarded or reinforced is more likely to itself (Katz & Goldberg, 1991). In other words, occur again. The family dog soon learns that hang- conditioned stimuli that have been paired with a ing around the kitchen table brings food. In this drug can exert considerable control over behavior. example, the food is a reinforcer because it increases the likelihood that the dog will spend time near the kitchen table. Thus, the dog’s behavior SUMMARY ‘‘operates’’ on the environment to produce an ef- To summarize, conditioned drug effects play an fect. This process is called operant conditioning. important role in the behavior stemming from drug The techniques of operant conditioning are used abuse. Stimuli correlated with the administration widely to establish new behaviors both in humans of a drug, as well as behavior in the presence of that as well as in animals. Because behavior that is operantly conditioned is very sensitive and reliable, drug, frequently result in those stimuli gaining con- it is often used to examine drug effects. siderable control over the discriminative effects or reinforcing effects of that drug (or both). Perhaps this is one of the main reasons that drug effects are A TYPICAL OPERANT CONDITIONING EXPERIMENT so compelling and problematic: Not only does the drug itself have powerful effects, but stimuli corre- In most operant conditioning experiments, an lated with the drug also acquire the ability to pro- animal is placed in a special chamber which is duce similar effects. called a Skinner box after the man that developed operant conditioning. A typical operant chamber, which is shown in Figure 1, has a response key or (SEE ALSO: Addiction: Concepts and Definitions; lever and a place for delivering food. The animal’s Causes of Substance Abuse; Memory and Drugs: responses are counted by a computer and also re- State Dependent Learning; Research) corded on a roll of paper that shows the distribution of responses over time. Although the experimental BIBLIOGRAPHY chamber in Figure 1 is designed for animals, operant conditioning procedures are also used to exam- GOLDBERG, S. R., & SCHUSTER, C. R. (1970). Condi- ine drug effects in humans. In these studies, the tioned nalorphine-induced abstinence changes: Per- person may sit in a chair and respond by moving a sistence in post morphine-dependent monkeys. Jour- joystick or perhaps sit at a keyboard and respond to nal of the Experimental Analysis of Behavior, 14,33– stimuli on a computer screen. 46. GOLDBERG, S. R., & SCHUSTER, C. R. (1967). Condi- SCHEDULES OF FOOD DELIVERY tioned suppression by a stimulus associated with nalorphine in morphine-dependent monkeys. Journal In most operant conditioning experiments in an- of the Experimental Analysis of Behavior, 10, 235– imals, responses on a lever or key produce food 242. according to some schedule. Behavior maintained KATZ, J. L., & GOLDBERG, S. R. (1991). Second-order by a schedule of reinforcement is called schedule- schedules of drug injection: Implications for under- controlled behavior. For example, the pigeon or rat standing reinforcing effects of abused drugs. In N. K. may have to make a specific number of responses in order to receive food. When this occurs, the organ- Mello (Ed.), Advances in substance abuse, behavior ism is responding under a fixed ratio schedule.A and biological research (Vol. 4). London: Jessica similar schedule is the variable ratio schedule in Kingsley. which reinforcement occurs after an unpredictable O’BRIEN, C. P. (1976). Experimental analysis of condi- number of responses. With both the fixed ratio and tioning factors in human narcotic addiction. Pharma- the variable ratio schedules, animals respond very cological Review, 27, 533–543. quickly, in fact, under a fixed ratio schedule that JAMES E. BARRETT requires thirty responses for food delivery, pigeons RESEARCH, ANIMAL MODEL: Operant Learning Is Affected by Drugs 1003

Figure 1 Diagram of an Operant Conditioning Chamber. When the pigeon presses the key, food is delivered. A separate device counts the number of times the pigeon pecks the key. SOURCE: L. S. Seiden, & L. A. Dykstra (1977). Figure 1 Diagram of an Operant mayConditioning respond as Chamber. fast as five When times a second. Another der a schedule of reinforcement that produces low operantthe pigeon schedule presses is the the key,fixed interval schedule in rates of responding than under a schedule of rein- whichfood is the delivered. first response A separate that occurs after a specified forcement that produces high rates of responding. perioddevice counts of time the produces number food. of With this schedule, Specifically, a small amount of AMPHETAMINE in- ratestimes of the responding pigeon pecks increase the as the time for food creases very low rates of responding, whereas the deliverykey. approaches. For example, in a fixed inter- same amount of amphetamine either decreases or valSOURCE five-minute: L. S. Seiden, schedule. & L. A. responding is very low does not change high rates of responding. Other Dykstra (1977). during the first two minutes of the interval; re- drugs in the amphetamine class such as COCAINE sponding picks up speed during the third and and METHYLPHENIDATE (Ritalin) also alter re- fourth minutes of the interval and becomes very sponding in a rate-dependent manner. rapid during the last minute, just before the food is One of the most interesting aspects of the rate- delivered. dependency theory of drug action is that it empha- By comparing drug effects on different schedules sizes the importance of behavioral as well as phar- of REINFORCEMENT, scientists have shown that the macological factors in determining a drug’s effect way in which a drug alters responding depends on on behavior. Thus, the rate at which an animal the rate of responding produced by a given sched- responds is an important determinant of the way in ule of reinforcement as well as the amount (or dose) which a drug alters behavior. It also helps to ex- of drug given. Thus, a drug’s effects are rate-de- plain why drugs such as amphetamine and methyl- pendent as well as dose-dependent. The rate-de- phenidate, which generally increase motor activity, pendency theory of drug action was first proposed might be useful in treating hyperactivity. Since hy- by Peter Dews in the early 1960s and is best exem- peractive children respond at a very high rate, am- plified by the effects of amphetamine. Dews noted phetamine would be expected to decrease these that amphetamine alters responding differently un- high rates of responding. 1004 RESEARCH, ANIMAL MODEL: Operant Learning Is Affected by Drugs

In contrast to the rate-dependent effects ob- sign of a typical punishment procedure. First, note served for amphetamine-like drugs. the most nota- in the first panel that responding maintained by ble effect of drugs such as MORPHINE is that they food alone occurs at a high rate. In the second decrease rates of responding under several different panel, responding is punished by the addition of an schedules of reinforcement. The extent to which unpleasant event and, as a result, rate of respond- morphine decreases rate of responding depends on ing is decreased during the punishment period. The how much morphine is given. Thus, its effects are third panel shows that a drug such as alcohol selec- dose-dependent. Moreover, like all schedule-con- tively affects responding during the punishment trolled behavior, these decreases in rate of respond- period by restoring rates of responding to their ing are very consistent and reliable. If a rat is baseline levels. Because these increases in punished trained to respond under a fixed ratio schedule of responding occur following alcohol as well as a food presentation and then given morphine, mor- number of other antianxiety agents, but not follow- phine will decrease rates of responding by about ing drugs such as morphine or amphetamine, in- the same amount each time it is given; however, if creases in punished responding may reflect the an- morphine is given daily for a week or more, its rate- tianxiety properties of these drugs. Indeed, the decreasing effects diminish. In other words, punishment procedure is used by a number of TOLERANCE develops. Interestingly, the develop- pharmaceutical companies to predict whether a ment of tolerance depends on the behavior exam- drug might be useful in treating anxiety. ined as well as how much drug is given. Morphine’s effects on responding under sched- SCHEDULES OF REINFORCEMENT AS ules of reinforcement are also used as a baseline to A WAY TO MEASURE LEARNING investigate the biochemical and physiological events that occur when morphine is given. Opioid Schedules of reinforcement are also used to ex- antagonists, which block the binding of morphine amine the rate at which new behaviors are learned. to opioid receptors, are able to reverse morphine’s Clearly, it takes some time to train an animal to effects on schedule-controlled behavior. Since mor- respond under a schedule of reinforcement. This phine’s effects on responding are blocked when period of training is called the acquisition period opioid receptors are blocked, these data suggest and provides a measure of learning. One way to that morphine produces its behavioral effects by design a learning experiment is to measure how interacting with opioid receptors. Responding un- long it takes a group of rats to learn to respond der schedules of reinforcement is also used to ex- under a schedule of reinforcement when a drug is amine the biochemical and physiological effects of given and compare that to how long it takes another drugs. For example, amphetamine’s effects other group of rats to learn the same task without a on schedules of reinforcement are altered by drugs drug. In experiments such as these, animals are that interfere with the neurotransmitter dopamine, usually trained to respond under very complicated suggesting that the dopamine system is involved in schedules of reinforcement. Sometimes the animal amphetamine’s behavioral effects. has to complete the requirements of several different schedules in order to obtain food; in other procedures, the animal responds differently in the SCHEDULES OF PUNISHMENT presence of different kinds of stimuli. In another Although schedule-controlled behavior gener- procedure, the time it takes an animal to learn a ally is maintained by the delivery of food, in some pattern of responses is determined when a drug is situations, responding is punished by the presenta- given and compared to the time it takes the same tion of an unpleasant event. In a typical punish- animal to learn a different pattern of responses ment procedure, responding is first maintained by a without a drug. ETHANOL, the BARBITURATES, and schedule of food delivery. Brief periods are then several antianxiety drugs all increase the number of added during which responding is both reinforced errors animals make in learning new response se- by food and also punished by an unpleasant event. quences. Studies using a similar procedure in hu- As a result, responding occurs at a lower rate dur- mans show that ethanol and certain antianxiety ing periods in which responding is punished than drugs also increase the number of errors people during unpunished periods. Figure 2 shows the de- make when they learn new response sequences. RESEARCH, ANIMAL MODEL: Operant Learning Is Affected by Drugs 1005

Figure 2 Diagram of a Typical Punishment Procedure. In the ﬁrst panel, responding is maintained by food alone. The second panel shows responding maintained by food as well as responding during a period in which responding is punished. During this period, responding is decreased. The third panel shows the effects of ethanol on punished responding.

SUMMARY The PSYCHOMOTOR STIMULANTS increase responding under schedules of reinforcement when Schedules of reinforcement offer several advantages for studying the behavioral effects of drugs. responding occurs at a low rate; when responding First, schedule-controlled responding is very con- occurs at higher rates, the psychomotor stimulants sistent and remains unchanged for long periods of decrease rates of responding. The most notable ef- time. This consistency makes it easy to examine fect of morphine is that it decreases overall rates of changes in behavior after a drug is given. Second, responding. Alcohol and the antianxiety agents are schedule-controlled behavior can be used with hu- unique in that they increase responding that is sup- man subjects as well as with several different ani- pressed by the presentation of a punishing stimu- mal species, including mice, rats, pigeons, and lus. Finally, several drugs interfere with the learn- monkeys. Finally, schedule-controlled behavior is ing of complex patterns of responding. recorded with automatic devices so that the experimenter is completely removed from the experiment and the nature of the behavior is easy to measure. (SEE ALSO: Adjunctive Drug Taking; Behavioral From these studies, several important concepts Tolerance; Memory and Drugs: State Dependent have emerged. Scientists have shown that the be- Learning; Memory, Effects of Drugs on; Reinforce- havioral effects of drugs depend not only on the ment; Tolerance and Physical Dependence) amount of drug given, but they also depend on the nature of the behavior being examined. Both the BIBLIOGRAPHY rate of occurrence of a behavior as well as the presence of punishing stimuli are very important CARLTON, P. L. (1983). A primer of behavioral pharma- determinants of how drugs alter behavior. cology. New York: W. H. Freeman. 1006 RESEARCH AND THE U.S. GOVERNMENT

MCKIM, W. A. (1986). Drugs and behavior. Englewood ally presented as rate-intensity (rate-frequency) Cliffs. NJ: Prentice-Hall. functions. If a drug shifts the rate-intensity func- SEIDEN, L. S., & DYKSTRA, L. A. (1977). Psychopharma- tion to the left, it is interpreted as an increase in cology: A biochemical and behavioral approach. New sensitivity of the animal to the rewarding stimula- York: Van Nostrand Reinhold. tion. A shift to the right is interpreted as a decrease LINDA A. DYKSTRA in sensitivity. Threshold (sometimes called locus of rise) is defined as the intensity that yields half the maximum rate of response for the animal. If the RESEARCH AND THE U.S. GOVERN- maximum rate becomes asymptotic at approxi- MENT See U.S. Government: Agencies Support- mately the same stimulus intensity as observed af- ing Substance Abuse Research ter saline, it is assumed that any phase shift is a direct effect of the drug on the reward value of the stimulation, not the result of a nonspecific motor REWARD PATHWAYS AND DRUGS effect of the drug. The observation that animals would work in order to receive electrical stimulation to discrete brain TWO-LEVER TITRATION areas was first described by Olds and Milner (1954). In this paper, they stated, ‘‘It is clear that In this procedure, rats are placed in a chamber electrical stimulation in certain parts of the brain, with two levers; pressing one of the levers results in particularly the septal area, produces acquisition rewarding stimulation, but at the same time the and extinction curves which compare favorably response attenuates the intensity of stimulation by with those produced by conventional primary re- a fixed amount. A response on the second lever ward.’’ This phenomenon is usually referred to as resets the intensity to the original level. The thresh- brain-stimulation reward (BSR), intracranial self- old is defined as a mean intensity at which the reset stimulation (ICSS), or intracranial stimulation response is made. (ICS). Most abused substances increase the rate of re- PSYCHOPHYSICAL DISCRETE sponse (lever pressing) for rewarding ICS, and this TRIAL METHOD has been interpreted as an increase in the reward value of the ICS. Because changes in rate of re- A wheel manipulandum is usually used, al- sponse could also be a function of the effects of the though the method has been employed using a drug on motor performance, a number of methods response lever. In this method, discrete trials are have been developed that control for the used, each demanding only a single response by the confounding nonspecific effects of the drugs under rat in order to receive the rewarding stimulation. A study, at least in part. The three most commonly trial consists of an experimenter-delivered (non- used procedures are phase shifts (Wise et al., contingent) stimulation. If the animal responds by 1992), two-level titration (Gardner et al., 1988), turning the manipulandum within 7.5 seconds, it and the psychophysical discrete-trial procedure receives a second stimulation at the identical stimu- (Kornetsky & Porrino, 1992). Using these thresh- lation intensity as the first stimulus. Current inten- old methods for determining the sensitivity of an sities are varied in a stepwise fashion or descending animal to BSR, there is general agreement that and ascending order. This yields a response-inten- most of the commonly abused substances do in fact sity function, with the threshold defined as the increase the sensitivity of animals to the rewarding intensity at which the animal responds to 50 per- action of the electrical stimulation and this action is cent of the trials. Of the methods currently used, independent of any motor effects of the substances. this is the only one that does not make use of the response rate as an integral part of the procedure PHASE SHIFTS for the determination of the reward threshold— In this method, rates of response are determined thus it is independent of the rate of response and at various intensities of stimulation. Data are usu- the possible confounding motor effects of the drug. ROCKEFELLER DRUG LAWS 1007

DOPAMINE AND ICS addiction. New York: Annals of the New York Acad- emy of Sciences, Vol. 654. Although most abused drugs lower the threshold for ICS for some drugs, the findings have not al- CONAN KORNETSKY ways been consistent, particularly with HALLUCINOGENS and the SEDATIVE-HYPNOTICS, including ALCOHOL (ethanol). For the most part, the RITALIN See Methylphenidate threshold-lowering effects caused by the abused substances are compatible with the hypothesis that facilitation of DOPAMINE is involved in their re- ROCKEFELLER DRUG LAWS The warding effects. Drugs that increase dopamine Rockefeller drug laws are a set of New York availability at the synapse facilitate ICS, and those MANDATORY SENTENCING statutes for drug crimes. that block dopamine transmission decrease ICS They were proposed by New York’s Governor Nel- (i.e., they raise the threshold—or the amount of son A. Rockefeller in reaction to a HEROIN epidemic current—needed to produce rewarding effects). in his state. These laws, which took effect on Sep- tember 1, 1973, require that judges impose lengthy prison sentences on drug traffickers, with a large DOPAMINE category of drug offenders receiving life imprison- Because abused substances clearly enhance the ment. The goal was to deter people from both drug rewarding value of the intracranial stimulation and use and trafficking by imposing tough and certain not simply cause a general increase in motor behav- punishments. Although the law was immediately ior, the brain-stimulation-reward model directly challenged as violating the Cruel and Unusual Pun- allows for the study of the neuronal mechanisms ishment clause of the U.S. and New York constitu- involved in the rewarding effects of abused sub- tions, the New York Court of Appeals unanimously stances. Although this is not as homologous a upheld the law model of drug-taking behavior as is the self-admin- Within a few years, however, the state’s prison istration model, it predicts as well as the self-ad- population began to swell, as increasing numbers of defendants were subjected to the provisions of the ministration model the ABUSE LIABILITY of compounds, and it readily lends itself to analysis of the Rockefeller laws. From 1969 to 1979, the prison mechanisms involved in the rewarding effects of population doubled, from 12,000 to 24,000. In the same time period, the percentage of incarcerated abused substances. nonviolent drug offenders increased from 10 percent to over 30 percent. In spite of these laws, the (SEE ALSO: Research, Animal Model ) crime rate continued to grow. A major evaluation concluded that neither drug use nor drug traf- BIBLIOGRAPHY ficking was reduced after the law was passed. The likelihood that a defendant, once arrested, would GARDNER, E. L., ET AL. (1988). Facilitation of brain be incarcerated did not increase—although the ⌬9 stimulation reward by -tetrahydrocannabinol, Psy- likelihood that a defendant, once convicted, would chopharmacology; 96, 142–144. be imprisoned did increase (Joint Committee on KORNETSKY, C., & PORRINO, L. J. (1992). Brain mecha- New York Drug Law Evaluation, 1977). nisms of drug-induced reinforcement. In C. P. The processing of cases became much more ex- O’Brien & J. H. Jaffe (Eds.), Addictive States. New pensive for New York. For every crime affected by York: Raven Press. the law, the percentage of defendants pleading OLDS, J., & MILNER, P, (1954). Positive reinforcement guilty fell, and the proportion of trials increased. produced by electrical stimulation of septal area and The evaluators concluded that it ‘‘took between ten other regions of rat brain. Journal of Comparative and fifteen times as much court time to dispose of a Physiology and Psychology; 47, 419–427. case by trial as by plea.’’ The average time to WISE, R. A., ET AL. (1992). Self-stimulation and drug handle a drug prosecution in New York City, for reward mechanisms. In P. W. Kalivas & H. H. Sam- example, doubled, rising from 172 days in 1973 to son (Eds.), The neurobiology of drug and alcohol 351 days in 1976. 1008 ROHYPNOL

Although the legislature realized the ineffec- BIBLIOGRAPHY tiveness of the stated purposes of the laws, neither it JOINT COMMITTEE ON NEW YORK DRUG LAW EVALUATION nor a succession of governors has proposed re- (1977). The nation’s toughest drug law: Evaluating pealing the laws. Instead, the legislature has sought the New York experience. Washington, DC: U.S. Gov- to amend the laws in ways that reduce their scope. ernment Printing Office. In 1977, the legislature removed marijuana from TSIMBINOS, S. A. (1999). Is it time to change the Rocke- the definition of crimes dealing with controlled sub- feller drug laws? St. John’s Journal of Legal Commen- stances and created a new sentencing law for mari- tary, 13, 613. juana sale and possession. The possibility of life imprisonment for marijuana offenses was elimi- MICHAEL TONRY nated. REVISED BY FREDERICK K. GRITTNER The legislature tinkered with the laws again in 1979. This time it increased the amount of weight of the drug necessary to trigger higher-level ROHYPNOL Known by a variety of street felonies. It also reduced the minimum sentence names such as roofies, roach, R-2, trip and fall, and range for certain drug convictions and eliminated a rope or ‘‘the date-rape drug,’’ rohypnol is the trade classification from the statute. The 1979 amend- name for the benzodiazepine FLUNITRAZEPAM,a ments also gave the courts the ability to retroac- sedative-hypnotic drug used medically in a number tively resentence defendants who had been con- of countries. Rohypnol has recently become a victed based on the original weight and widely abused drug in Sweden, Mexico, Italy, the classification schemes. United Kingdom, the United States, and South Af- Despite these changes, they have done little to rica, a trend made more troubling by the fact that reduce the harshness of the sentencing practices or many users regard it as relatively safe. Rohypnol, in reduce the prison population. In 1998, the state fact, has many dangerous and undesirable effects prisons held 70,000 inmates, three times the num- for the illicit user. It has been associated with an ber incarcerated in 1979. Most significantly, 30 increased risk of violence and accidents as well as percent of the prison population is comprised of stupor, coma, memory loss, and death. Its ability to nonviolent drug offenders. induce unconsciousness and amnesia has led to its By the late 1990s, many in the legal community use in sexual assaults in the United States (hence, argued for repeal of the Rockefeller laws, believing its reputation as a date-rape drug) as well as rob- that they imposed disproportionate punishment on beries. nonviolent drug offenders and ignored drug treat- Although never approved for use in the United ment options. However, Governor George Pataki States (where it is illegal) rohypnol is a commonly responded in 1999 with only a minor change in the prescribed BENZODIAZEPINE in Europe and else- laws. Pataki proposed legislation that slightly alters where. Like other benzodiazepines, such as VALIUM the laws by offering first-time drug couriers a chance (DIAZEPAM) or Xanax (Alprazolam), it is useful in to cut their sentences by five years. Under this the medical treatment of sleep disorders and anxi- proposal, the appellate courts would be allowed to ety, though only under supervision by a doctor. review and reduce sentences by five years for first- Benzodiazepines act at brain receptors for the in- time felony offenders under the harshest provision hibitory neurotransmitter GABA, which is also the of the laws, which now calls for a maximum of site of action for another, older class of sedative- fifteen years to life. This proposal was similar to one hypnotic drugs and barbiturates. Although gener- proposed by Chief Judge Judith S. Kaye, who also ally safer than barbiturates, benzodiazepines like called for allowing trial judges to defer the prosecu- rohypnol share some of the same dangers especially tion of nonviolent drug offenders for up to two years when mixed with ETHANOL, a common practice and to divert them to drug treatment programs. among illicit drug users. These dangerous effects However, the legislature did not act on these reform range from incontinence, behavioral disinhibition, efforts, leaving the status quo in place. violence, delirium, and black-outs to stupor, respiratory depression, and death. These effects all stem (SEE ALSO: Drug Laws, Prosecution of; Opioids and from the ability of rohypnol to depress brain func- Opioid Control: History) tion. ROLLESTON REPORT OF 1926 (U.K.) 1009

At lower doses, benzodiazepines can reduce anx- were given importance along with punishment and iety and cause relaxation and a loosening of inhibi- criminal penalties. The British policies were, in this tions somewhat similar to the effects of ALCOHOL, sense, different from U.S. policies toward drugs another drug that acts as a depressant on the cen- that emerged during the same period and in re- tral nervous system. As with many abused drugs, sponse to similar international agreements. The the continued use of rohypnol results in increased historical background leading to the formation of tolerance, requiring larger doses to produce the an elite committee of British physicians, chaired by same effects. Larger doses mean narrower margins Sir Humphrey Rolleston, had four major phases. of safety and the increased incidence of side effects, especially memory loss and deficits in learning. ENDING THE COMMERCIAL Drinking alcohol in combination with rohypnol OPIUM TRADE makes serious consequences all the more likely. Of still greater concern for the illicit user is that chron- During the nineteenth century, the British estab- ic use of sedative-hypnotic drugs like rohypnol can lished commercial opium trading by fighting and produce a level of physiologic dependence greater winning two Opium Wars with China: Opium than that resulting from OPIATE drugs like HEROIN grown and sold by monopoly in British-dominated or MORPHINE. Abrupt WITHDRAWAL from regular India provided a quarter of the revenue for the use can produce complications ranging from the British government in India. Prepared opium (for relatively mild, such as restlessness and anxiety, to smoking) was exported to Chinese ports by the East more severe effects like tremor, hallucinations and India Company, where British authorities collected convulsions similar to those experienced during se- tax revenues on it for the Chinese government. vere alcohol withdrawal. These complications can Missionaries in China and their anti-opium allies in be best avoided through a medically supervised Britain, the United States, and Canada lobbied withdrawal. strongly against profiting from the British-spon- Rohypnol has received much media attention in sored vice. They also educated the public about the United States for its apparent involvement in a opium smoking and commercial opium trading. number of sexual assaults or rapes. Because it can The U.S. government stimulated the convening quickly render an unsuspecting victim uncon- of several international conferences from 1909 to scious, rohypnol lends itself to this kind of crime. 1914. These conferences reached agreements that As rohypnol is odorless and tasteless and easily all signatory governments would enact legislation dissolved in drinks, it can be offered to a victim ending commercial opium trading and restricting without arousing suspicion. Although media atten- opium and cocaine to ‘‘legitimate medical prac- tion has focused on particular drugs like rohypnol tice.’’ The Indo-Chinese opium trade ended in and GHB, it should be noted that a variety of drugs 1914. These international conventions were in- can and are being used in this manner, including cluded in the Versailles Treaty that ended World barbiturates, opiates, other benzodiazepines and War I. ‘‘Legitimate medical practice’’ and appro- ethanol. Ethanol remains several times more likely priate controls and/or penalties were not specified to be associated with sexual assault than any other in the international treaties. drug, including rohypnol, even though rohypnol and drugs like it are more effective in rapidly pro- OPIUM CONTROLS AND GROWTH OF ducing the stupor and memory loss desired by this THE MEDICAL PROFESSION type of criminal. During the nineteenth century, opiates were the RICHARD G. HUNTER only effective way to relieve the symptoms of many physical ailments (most medicines used today, including aspirin, became available only in the twen- ROLLESTON REPORT OF 1926 (U.K.) tieth century). OPIUM and its derivative MORPHINE The Rolleston Report of 1926 helped to establish (Britain was the world’s leading manufacturer) British policy toward OPIATES,COCAINE, and other were available in patent medicines, in alcoholic drugs. It institutionalized a drug policy in which solutions, and in other commercial products. The medical expertise and public-health considerations emerging professions of pharmacist and medical 1010 ROLLESTON REPORT OF 1926 (U.K.) physician with advanced training and specialized mary responsibility. He suggested using the War knowledge were anxious to differentiate themselves Powers Act to stop sales of cocaine and opiates to from a motley group of healers—chemists, soldiers unless they were based on a prescription by herbalists, barber-dentists, patent-medicine a doctor that was ‘‘not to be repeated’’ (refilled sellers, and others. In the 1850s, such persons without further prescription). Violators, however, could provide opiates to patients since they were could be fined only five pounds. Two or three cases not then illegal, and preparations containing opi- were publicized and introduced the British public ates provided substantial revenues. Opium eating to ‘‘dope fiend’’ fears, but they continued to be rare. and LAUDANUM (an alcoholic solution of opiates) After World War I, Delevingne argued that drug consumption were then widespread in Britain. control was a police responsibility for the Home British pharmacists became eager to restrict Office (where it has remained ever since). The 1920 sales of opiates to qualified sellers—but only in Dangerous Drug Act was vague about two critical such a way that ‘‘professional’’ trade would not be issues—whether doctors/pharmacists could pre- harmed and could be expanded. The 1868 Poisons scribe for themselves, and whether doctors could Act restricted opiate sales to pharmacists. This act ‘‘maintain’’ addicts. In 1921 and 1924, the Home mandated the labeling of opiates and required Office proposed regulations that ignored the rights pharmacists to keep records of purchasers. (Similar of professionals and imposed many complex proce- restrictions on opiate sales in the United States did dures. It also sought powers of search and seizure, not occur until the 1906 Food and Drug Act.) Phar- higher fines, and longer sentences for convictions. macists, however, could continue to sell opiates di- Thus, the Home Office was making regulations that rectly to customers without a prescription from a would subject doctors to criminal sanctions and physician, and physicians could prescribe or sell circumscribe their prescribing practices—as was opiates to patients. In the early 1880s physicians already happening in the United States. and researchers in Europe, England, and the United States almost simultaneously began to write APPOINTMENT OF THE about the opium habit and morbid cravings for ROLLESTON COMMITTEE opiate drugs. In 1884 physicians in England founded the Society for the Study of Inebriety, The Home Office needed the cooperation of the which promoted a disease model of addiction and medical profession to determine the appropriate- the need for treatment. ness of maintenance dosages for addicts, and it By 1900, physicians emerged as an elite group sought to determine whether gradual reduction was who defined all aspects of health care and medical the appropriate treatment for addiction. The Home practice in British society; pharmacists ‘‘policed’’ Office and the medical profession each recognized the Poisons Act and effectively retained control of the legitimacy of the other’s position. Both realized dispensing opiates and other drugs. Thus, by 1914, that a partnership was needed. Thus, these two British pharmacists and physicians had almost a elite groups began a collaboration to define and half century of experience, professional collabora- resolve problems and appropriate practices regard- tion, an ongoing professional association concerned ing narcotics control. All persons appointed to the with the dispensing of opiates, and attempts to con- committee were medical personnel representing tain opiate consumption and habitual use. government agencies or nongovernment physician- interest groups. The chairman, Sir Humphrey Rolleston, was president of the Royal College of PRESSURE TOWARD Physicians and a noted exponent of the disease CRIMINAL PENALTIES view of ALCOHOLISM. Another member had written In 1914, when the international opium conven- the authoritative article on narcotic addiction in tion (Hague Convention) was to go into effect, sev- 1906. Police and law enforcement officials without eral British agencies could not decide which one medical training were not represented. should take responsibility for implementing legisla- Committee Deliberations and Recommen- tion and regulation of drugs. Then World War I dations. The committee was to consider and ad- began in August 1914 and Sir Malcolm Delevingne, vise as to the circumstances, if any, in which the an undersecretary at the Home Office, took pri- supply of morphine and heroin (including prepara- ROLLESTON REPORT OF 1926 (U.K.) 1011 tions containing morphine and heroin) to persons tribunal was established to promote the profes- suffering from addiction to these drugs, may be sion’s own policing of members who became ad- regarded as medically advisable and as to the predicted. The committee also opposed banning heroin cautions which it is desirable that medical practi- (which was a useful medication and a very small tioners administering or prescribing morphine or problem in Britain at the time). heroin should adopt for the avoidance of abuse, and to suggest any administrative measures that LEGACY OF THE REPORT seem expedient for securing observance of these precautions. Shortly after the Rolleston Report was com- During a year and a half of deliberations and pleted, its recommendations were included in twenty-three meetings, the committee heard evi- amendments to the Dangerous Drug Act (1926). dence from thirty-four witnesses. The Home Office Although this act has been amended numerous submitted a memorandum that structured the times since then, the provisions adopted from the questions and inquiry. Witnesses represented a Rolleston Report remain in effect in the 1990s. wide diversity of opinion, particularly regarding Although cocaine was included as a narcotic in appropriate treatment for addicts. Prison doctors this report, separate recommendations for treat- favored harsher treatment, especially abrupt with- ment were not made. Cannabis (MARIJUANA) was drawal of opiates (going cold turkey). Even consul- not included in this report. The Rolleston Report tants specializing in treatment rarely agreed on did not address the issue of illegal sales or trans- points of procedure and treatment. Most witnesses fers of opiates; no criminal or penal sanctions were and commission members accepted the disease na- recommended. ture of addiction. The British Medical Journal was content: The There was wide agreement, however, that ad- medical view of addiction as a disease needing diction to HEROIN or morphine (both opiates) was treatment, and not a vice necessitating punishment a rare phenomenon and a minor problem in BRIT- and penal sanction, had been formally accepted as AIN. Most addicts were middle class and many government policy. Medical professionals, rather were members of the medical profession. Rela- than criminal-justice personnel, would be responsi- tively few criminal or lower-class addicts were ble for individual decisions about whether patients then known, so criminal sanctions appeared were addicts, and prescribe appropriate quantities unneeded and inappropriate. The committee re- of opiates, including on a maintenance basis. Any port concluded that ‘‘the condition must be re- questions about appropriate prescribing practices garded as a manifestation of disease and not as a and physician addiction would be handled by a mere form of vicious indulgence.’’ committee specializing in addiction. As a result, From this conclusion, many recommendations almost no British physician has been arrested and/ followed. The most important was that some ad- or tried for opiate-related violations. dicts might need continued administration of mor- The foundations of what is sometimes called the phine (or other opiates) ‘‘for relief of morbid condi- British system of drug policy had been established. tions intimately associated with the addiction.’’ From 1926 to 1960, this system worked well. Thus, the committee effectively supported mainte- Names of fewer than 1,000 addicts were forwarded nance of an addict for long periods of time, possibly to the Home Office each year, most of them medical for life. personnel. Local practitioners could and did pre- The committee also made several recommenda- scribe heroin and other opiates to their patients, tions for administrative procedures to lessen the including registered addicts. Some addicted pa- severity of the drug problem. Practitioners were tients were maintained on heroin, occasionally for mandated to notify the Home Office when they years. They received their drugs from a local phar- determined someone was addicted; but physicians macy. Addicts were also provided with clean nee- could continue to provide treatment and prescribe dles and syringes. Drug treatment consisted almost opiates to addicts. Gradual reduction rather than entirely of individual physicians counseling ad- abrupt withdrawal was the recommended treat- dicted patients and providing drugs. Almost no ment, in part to keep addicts in treatment rather illicit sales of opiates or cocaine occurred during than to drive them to illicit suppliers. A medical these years. One staff member at the Home Office 1012 ROOFIES was responsible for all registrations and personally ties. It is also used for massages and by athletic knew most of the addicts in Britain; he frequently trainers to treat skin and muscle groups, hence the helped addicts find doctors and/or assistance. The term rubbing. It has a drying effect on the skin and Home Office also covened meetings with addiction causes blood vessels to dilate; its distinctive odor is specialists to address any policy issues that arose. associated with doctor’s offices, since it is used to Thus, the British established what might be de- clean the skin being prepared for an injection. scribed as a system of drug control that gave due When rubbing alcohol is ingested either pure or weight to medical values and public-health consid- added to beverages, the result is toxic—with symp- erations. Most observers now agree, however, that toms lasting longer than those seen after drinking the ‘‘system’’ worked because the problem was lim- ethanol (alcoholic beverages), because isopropyl ited in size rather than that the problem was small alcohol is slowly metabolized to acetone, another because of the system. It worked well for half a toxic substance. century until the numbers of addicts increased substantially, because of drug dealing on an interna- (SEE ALSO: Inhalants) tional scale, the widespread use of drugs during the 1960s–1980s countercultural revolution, and the BIBLIOGRAPHY increased immigration to Britain of former colonial citizens of the crumbling empire. By the 1960s, the CSAKY, T. Z., & BARNES, B. A. (1984). Cutting’s hand- upsurge in heroin use and the abuse of cocaine, book of pharmacology, 7th ed. Norwalk, CT: Apple- marijuana, and other drugs left Britain with a drug ton-Century-Crofts. problem of both licit and illicit substances that S. E. LUKAS outstripped even the British system’s handling capabilities. RUSH See Slang and Jargon (SEE ALSO: Britain, Drug Use in; British System of Drug-Addiction Treatment; Heroin: The British System; International Drug Supply Systems; Opi- RUTGERS CENTER OF ALCOHOL oids and Opioid Control: History; Policy Alterna- STUDIES For all the years of its existence, the tives: Prohibition of Drugs Pro and Con; Sweden, Rutgers Center of Alcohol Studies (initially Drug Use in) founded in 1940 as the Yale Center in New Haven, Connecticut) has been centrally involved in gener- BIBLIOGRAPHY ating significant research findings on alcohol, alco-

BERRIDGE, V. (1980). The making of the Rolleston Re- holics, and alcoholism. Through those same years, port 1908–1926. Journal of Drug Issues, Winter,7– the center’s mission has also included education, 28. service, and information dissemination to the university community of which it was a part, the na- BRUCE D. JOHNSON tion, and the world. The Center of Alcohol Studies was founded at Yale University by Professor E. M. JELLINEK; it was ROOFIES See Rohypnol; Slang and Jargon developed from the well-known Yale Laboratory of Applied Physiology, directed by Professor Howard W. Haggard, which first began to study the physiol- RUBBING ALCOHOL Rubbing alcohol is ogy of alcohol (ethanol) in the 1930s. In recogni- known as isopropyl alcohol (C3H8O); it is one of the tion of the paucity of scientific journals publishing more useful of the commercial alcohols, included in work on alcohol and alcoholism then, faculty at the hand lotions and many cosmetic items as well as in center founded The Quarterly Journal of Studies on antifreeze or deicer products. A 70 percent solution Alcohol in 1940. The journal’s first issue was edited has more germicidal properties than does ETHANOL by Professor Haggard; shortly thereafter, Mark (drinking alcohol), so it is used in many health-care Keller, a longtime editor of the Quarterly Journal, situations, both in households and in medical facili- became the journal’s managing editor. Keller RUTGERS CENTER OF ALCOHOL STUDIES 1013 served as editor of what is now the Journal of Stud- In December 1994, Rutgers University approved ies on Alcohol for more than thirty years as a a proposal by the Center to create the Rutgers faculty member of the Center of Alcohol Studies at Center of Alcohol Studies Faculty Practice Plan. both Yale and Rutgers, and also became a very This program provides assessment, intervention, substantial figure in the alcohol field by virtue both and referral services to alcohol abusers who need of his position and his many carefully wrought, help. The Center also offers the Drinkers Risk Re- penetrating, insightful talks and articles on a wide duction Program (DRRP), which was created for range of alcohol-related subjects. individuals concerned with their own drinking or Recognizing the absence at the time of methods the drinking of a loved one. DRRP employs both an and agencies for the dissemination of the practical assessment and intervention program, including a results of research on and experience with alcohol comprehensive interview, self-change program, problems, the faculty of the center founded the self-control training, and a referral service. Summer School of Alcohol Studies (SSAS) in 1943. The Center for Alcohol Studies’ Basic Sciences It was then and continues today to be oriented Division conducts research on a number of projects, toward meeting the needs of persons who work from alcohol and stress to the study of the effects of directly with the problems of alcohol use and alco- acute intoxication on people. The Clinical Research holism. The SSAS attracts students from around Division explores addiction assessment and re- the world for its one- and three-week residential search. The Education and Training Division con- summer programs. ducts numerous one-day seminars throughout the The pressing informational needs of the infant academic year. Seminar topics not only include all field of alcohol studies led to the development of the aspects of alcohol and alcohol abuse, but also touch library of the Center of Alcohol Studies, which now upon such subjects as gambling, HIV and AIDS, possesses the most complete special collection on and tobacco. alcohol and alcoholism in the world, along with a In 1962, the Center of Alcohol Studies moved to complete collection of journals and books on alco- Rutgers University, New Brunswick, New Jersey, hol and related subjects. The research library now into a building funded in part by a generous gift maintains a collection of more than 100,000 mate- from R. Brinkley Smithers. From that time until he rials. The Classified Abstract Archive of the Alcohol retired from Rutgers in 1975, Professor Seldon Ba- Literature contains about 20,000 abstracts of sci- con headed the Center of Alcohol Studies. A distin- entific work from a wide range of disciplines cross- guished sociologist who had joined the center’s fac- indexed in depth up to 1976; the McCarthy Collec- ulty shortly after it was founded at Yale, Bacon tion of original scientific papers; the Ralph G. played a key role for several decades in many of the Connor Collection of Alcohol-Related Research In- most important developments in alcoholism na- struments; and several extensive, continuously up- tionally. At the Center of Alcohol Studies, he was dated bibliographic series. The library’s users in- instrumental in expanding the Yale Plan, develop- clude students, educators, and health service ing the Summer School of Alcohol Studies, and professionals. nurturing the social-science research base that con- Faculty at the Yale Center of Alcohol Studies tinues to be one of the center’s major contributions. initiated the first research program on treatment, as In 1985, Smithers gave the center another ex- well as the Yale Plan on Alcoholism for Industry—a tremely generous gift, permitting it to add to its forerunner of modern EMPLOYEE ASSISTANCE PRO- building as well as to establish a prevention center GRAMS (EAPs). Center faculty also founded the first and an annual prevention symposium. State Commission on Alcoholism. The research faculty at the center has continued to grow. By the (SEE ALSO: Addiction Research Foundation of On- mid-1990s, it comprised a substantial number of tario (Canada); U.S. Government Agencies) biochemists and physiologists, sociologists and psychologists, epidemiologists and preventionists—all BIBLIOGRAPHY engaged in studying an array of topics from etiology and physiology to prevention and treatment, MENDELSON,J.H.&MELLO N. K. (1989). Studies of with relevance to alcohol, alcoholics, and alcohol- alcohol: Past, present, and future. Journal of Studies ism. on Alcohol, 50, 293–296. 1014 RUTGERS CENTER OF ALCOHOL STUDIES

NATHAN, P. E. (1989). The Center of Alcohol Studies and STRAUS, R. (1993). In memoriam: Selden D. Bacon. Jour- the Journal of Studies on Alcohol: Celebrating 50 nal of Studies on Alcohol, 54, 130–132. years. Journal of Studies on Alcohol, 50, 297–300. PETER E. NATHAN NATHAN, P. E. (1987). Reports from the research cen- REVISED BY MATTHEW MISKELLY tres—Rutgers: The Center of Alcohol Studies. Journal of Addiction, 82, 833–840. S

SADD See Students Against Destructive Deci- course of the disorder. It is likely that schizophrenia sions constitutes a group of disorders rather than a single entity; these disorders present with similar clinical signs and symptoms, but the etiologies, treatment SAFE USE OF DRUGS See Prohibition of responsiveness, and course of illness in each vary. Alcohol Detailed descriptions of the illness date back to the nineteenth century. Emil Kraepelin (1856– 1926) used the term dementia praecox to describe SAMHSA See U.S. Government Agencies psychiatric states with an early onset and deterio- rating course. Eugen Bleuler (1857–1939) coined SAODAP See U.S. Government Agencies the term schizophrenia for a ‘‘splitting of the mind,’’ in his belief that the illness was a result of the disharmony of psychological functions. The di- SCHIZOPHRENIA Schizophrenia is a psy- agnosis of schizophrenia requires observation and chiatric illness that can be profoundly disabling clinical interviewing. No sign or symptom is specific and is usually chronic in nature. The cause is not for the illness, nor do any laboratory tests exist to known, but there appears to be a genetic predispo- establish the diagnosis. The DIAGNOSTIC AND sition. The etiology has been conceptualized in a STATISTICAL MANUAL for Mental Disorders-3rd edi- stress/diathesis (vulnerability) model: Biological tion contains the diagnostic guidelines of the Amer- and environmental factors (e.g., drug abuse, psy- ican Psychiatric Association for schizophrenia. chosocial stresses) interact with a genetic vulnera- These include: the presence of characteristic psy- bility to precipitate the illness. Several theories chotic symptoms (delusions, HALLUCINATIONS,a have been proposed to explain the observed biolog- thought disorder, inappropriate emotion); im- ical abnormalities of the disorder, including over- paired work, social functioning, and selfcare; and activity of the dopamine neurotransmitter systems continuous signs of the illness for at least six in the central nervous system, changes in brain months. The symptoms of an affected individual structure (e.g., enlargement of the lateral cerebral can change with time, therefore longitudinal fol- ventricles) and brain function (e.g., decreased fron- low-up is important. It should be noted that certain tal lobe function [hypofrontality], as evidenced by of these symptoms can be indicative of other condi- diminished blood flow, and deficits in attention and tions (including drug abuse [cocaine, crack, PCB, sensory filtering). Psychological and social factors amphetamines], head injury, brain tumors, as well are considered important in the expression and as other psychiatric disorders). Furthermore, it is

1015 1016 SCHIZOPHRENIA important to take into account the educational between January 1993 and March 1999, fifteen level, intellectual ability, and cultural affiliation of developed myocarditis, and eight developed car- the individual when making a diagnosis. The onset diomyopathy; a total of six patients died within the of illness is usually in late adolescence or early six years. adulthood and is generally insidious. The typical After a person has recovered from an acute epi- course of schizophrenia is characterized by exacer- sode of schizophrenia, the emphasis is on practical bations and remissions. A gradual deterioration in aspects of management: living arrangements, self- functioning generally occurs that eventually care, employment, and social relationships. Educa- reaches a plateau. However, a small proportion of tion of and support made available to family mem- persons may recover. It is estimated that 20 percent bers are important and can have an impact on to 30 percent of affected individuals can lead some- relapse rates in the patient. Many schizophrenic what normal lives whereas another 20 to 30 per- patients have to remain on antipsychotic medica- cent continue to experience moderate symptoms. tion for prolonged periods, since the rate of relapse The prevalence rates of schizophrenia vary to a is high after drug discontinuation. Side effects, pri- limited degree worldwide, but in the United States marily of a neurologic nature (e.g., TD), are a the lifetime prevalence is estimated to be 1 percent source of concern, but in most cases the benefits of (about one in one-hundred people). In industrial- symptom control outweigh the risks of phar- ized countries, there is a disproportionate number macotherapy. Making sure that the patient com- of schizophrenic patients in the lower socioeco- plies with medication use is often a problem. nomic classes. Some experts feel this is due to the schizophrenic’s loss of education and social oppor- (SEE ALSO: Amphetamine; Cannabis sativa; Com- tunity, while others feel this is more a direct result plications: Mental Disorders) of the stresses of poverty. The management of affected individuals involves hospitalization when there is an exacerba- BIBLIOGRAPHY tion of the illness, plus the use of medication. The ANDREASEN, N. C. (1986). Schizophrenia. In A. J. mainstay of pharmacologic treatment is the class of Frances & R. E. Hales (Eds.), Psychiatry update— drugs known as ANTIPSYCHOTICS. Many antipsy- The American Psychiatric Association annual review chotics are available and they act to control the (Vol. 5). Washington, DC: American Psychiatric psychotic symptoms; most of them do so by block- Press. ing the actions of the neurotransmitter, dopamine. APGAR, B. (1999). Antipsychotic drugs for treatment of About 75 percent of patients respond to these schizophrenia. American Family Physician, 60, 1220. drugs; however, there are side effects, including BERKOW, R. (Ed.) (1997). The merck manual of medical muscle stiffness, tremors, and weight gain. The information—home edition. Whitehouse Station, NJ: drugs may also cause tardive dyskinesia (TD), a Merck Research Laboratories. disorder that causes involuntary, repetitive move- KARNO, M., ET AL. (1989). Schizophrenia. In H. I. Kaplan ments of the body, mouth, and tongue. & B. J. Sadock (Eds.), Comprehensive textbook of Some of the more commonly prescribed antipsy- psychiatry (5th ed., Vol. 1). Baltimore, MD: Williams chotics include: chlorpromazine, fluphenazine, hal- & Wilkins. operidol, olanzapine, and risperidone. The atypical antipsychotic, clozapine, has been identified as the KILIAN, J. G., ET AL. (1999). Myocarditis and cardiomy- best choice for managing resistant schizophrenia; opathy associated with clozapine. The Lancet, 354, however, up to 73 percent of patients treated with 1841. clozapine report clinically relevant side effects. OLDHAM, J. M. (1995). Schizophrenia and psychosis. In These can be quite severe, and include potentially G. J. Subak-Sharpe, M. S. (Ed.), The Columbia uni- fatal neuroleptic malignant syndrome (NMS), my- versity college of physicians & surgeons complete ocarditis, cardiomyopathy, and dangerous lower- home medical guide (3rd ed.). NewYork: Crown ing of white blood cell count (for the latter, regular Publishers, Inc. and frequent blood testing is required during the MYROSLAVA ROMACH treatment period). In a study following 8,000 pa- KAREN PARKER tients in Australia who started clozapine treatment REVISED BY KIMBERLY A. MCGRATH SECOBARBITAL 1017

SCHOOLS AND DRUGS See Education (Eds.), The pharmacological basis of therapeutics, and Prevention 9th ed. (141–160). NewYork: McGraw-Hill. HOUGHTON, P. J., & BISSET, N. G. (1985). Drugs of ethno-origin. In D. C. Howell (Ed.), Drugs in central SCID See Structured Clinical Interviewfor nervous system disorders. NewYork: Marcel Dekker. DSM-IV ROBERT ZACZEK

SCOPOLAMINE AND ATROPINE Sco- SECOBARBITAL Secobarbital, prescribed polamine (d-hyoscine) and attopine (dl-hy- and sold as Seconal, is a short-acting BARBITURATE osycamine) is a tropane alkaloid found in the leaves used principally as a SEDATIVE-HYPNOTIC drug but and seeds of several plant species of the family occasionally as a preanesthetic agent. It is a non- Solanaceae, including deadly nightshade (Atropa specific central nervous system (CNS) depressant bella-donna) and henbane (Hyoscyamus niger). and greatly impairs the mental and/or physical Atropine, a major alkaloid in deadly nightshade, is abilities necessary for the safe operation of automo- also found in JIMSONWEED (Datura stramonium). biles and complex machinery. In Europe, in centuries past, henbane was a component of socalled witches’ brews or was applied as an ointment to mucous membranes. According to some folktales, the idea that witches fly on broomsticks was derived from the sensation of a flying experience after the use of such ointments. Scopolamine and atropine have very similar actions. They act as competitive antagonists at both peripheral and central muscarinic cholinergic re- Figure 1 ceptors. Scopolamine is still sometimes used clini- Secobarbital cally for the treatment of motion sickness. The compound also causes central nervous system de- Before the introduction of the BENZODIAZEPINES, pression, leading to drowsiness, amnesia, and fa- it was the drug most commonly used to treat insom- tigue. It also has some euphoric effects and abuse nia. Prolonged or inappropriate use of secobarbital liability, but these are not considered to be of such can produce TOLERANCE AND PHYSICAL DEPEN- magnitude to require control of the drug under the DENCE. If high doses have been used, abrupt cessa- Controlled Substances Act. Attopine has fewer actions on the central nervous system than scopola- tion can result in severe WITHDRAWAL symptoms mine. It is used to reduce actions at peripheral that include convulsions. Secobarbital is more cholinergic structures—it produces decreased gas- likely to be abused than benzodiazepines and ap- tric and intestinal secretions as well as spasms and pears to produce greater euphoria in certain indi- also results in pupillary dilation. It blocks the ac- viduals than would a comparable sedative dose of a tion of the vagus nerve that results in slowing of the benzodiazepine. Consequently, it is classified as a heart. It is often used before operations to prevent Schedule II class drug in the CONTROLLED SUB- unwanted reflex slowing of the heart beat. STANCES ACT, which indicates that although it is High doses of either of these tropane alkaloids acceptable for clinical use, it is considered to have a can cause confusion and delirium accompanied by high abuse potential. As with other barbiturates, it decreased sweating, dry mouth, and dilated pupils. should never be combined with another CNS depressant because respiratory depression can occur.

BIBLIOGRAPHY (SEE ALSO: Abuse Liability of Drugs: Testing in BROWN, J. H., TAYLOR, P. (1996). Muscarinic receptor Humans; Drug Interaction and the Brain; Drug agonists and antagonists. In J. G. Hardman et al. Interactions and Alcohol ) 1018 SECONDHAND SMOKE

BIBLIOGRAPHY recovery. SOS shares with other self-help groups the importance of anonymity and the abstention HOBBS, W. R., RALL, T. W., & VERDOORN, T. A. (1996) from all drugs and alcohol. Hypnotics and sedatives; ethanol. In J. G. Hardman et SOS consists of a nonproﬁt network of autono- al. (Eds.), The pharmacological basis of therapeutics, mous nonprofessional local groups dedicated solely 9th ed. (361–396). NewYork: McGraw-Hill. to helping individuals with alcohol and other drug SCOTT E. LUKAS addictions. It encourages and is supportive of continued scientiﬁc inquiry into the understanding of alcoholism and drug addiction. SECONDHAND SMOKE See Tobacco: Among other self-help organizations that see Medical Complications themselves as alternatives to AA are RATIONAL RE- COVERY (RR) and Women for Sobriety (WFS). SECONOAL See Secobarbital (SEE ALSO: Coerced Treatment for Substance Of- fenders; Disease Concept of Alcoholism and Drug Abuse; Treatment Types) SECULAR ORGANIZATIONS FOR SO- BRIETY (SOS) Secular Organizations for So- JEROME H. JAFFE briety (SOS National Clearinghouse, P.O. Box 5, Buffalo, NewYork 14215) is a self-help organization for alcohol and drug users, founded as an SEDATIVE Sedative is a general term used alternative to ALCOHOLICS ANONYMOUS (AA) and to describe a number of drugs that decrease activ- other groups based on AA. It was intended to offer ity, moderate excitement, and have a calming ef- help to people who are uncomfortable with the em- fect. The primary use for these drugs is to reduce phasis on spirituality that is a central tenet of the ANXIETY, but higher doses will usually cause sleep AA Twelve-Step Programs. Founded by James (a drug used primarily to cause sleep is called a Christopher, SOS began with a 1985 article. ‘‘So- hypnotic). Although the term sedative is still used, briety without Superstition,’’ describing Christo- the drugs usually prescribed to produce this calm- pher’s own path to sobriety. SOS claimed in 1991 ing effect are BENZODIAZEPINES, which are more to have an international membership of 20,000, commonly known as antianxiety agents, or minor making it the largest of the alternative groups. In tranquilizers. 1987, it was recognized by the State of California as an alternative to AA in sentencing offenders to (SEE ALSO: Barbiturates; Drug Types; Sedative- mandatory participation in drug rehabilitation. Hypnotic) Members of SOS are not necessarily nonreligious; however, many do not believe in an intervening BIBLIOGRAPHY higher power who takes responsibility for their individual problems. HOBBS, W. R., RALL, T. W., & VERDOORN, T. A. (1996) Unlike AA—which emphasizes that the individ- Hypnotics and sedatives. In J. G. Hardman et al. ual is powerless over alcoholism and must look to a (Eds.), The pharmacological basis of therapeutics, ‘‘higher power’’ for help in achieving and main- 9th ed. (361–396). NewYork: McGraw-Hill. taining sobriety—SOS and other alternative orga- SCOTT E. LUKAS nizations assert the capacity of individuals to control their own behavior. SOS stresses total abstinence, personal responsibility, and self-reli- SEDATIVE-HYPNOTIC Sedative-hyp- ance as the means to achieve and maintain sobriety notic drugs are used to reduce motor activity and (recovery), but the organization recognizes the im- promote relaxation, drowsiness, and sleep. The portance of participating in a mutually supportive term is hyphenated because, by adjusting the does, group as an adjunct to recovery. Members learn the same group of drugs can be used to produce that open and honest communication aids in mak- mild sedation (calming, relaxation) or sleepiness. ing the appropriate life choices that are essential to Thus, the distinction between a sedative and a SEDATIVES: ADVERSE CONSEQUENCES OF CHRONIC USE 1019

hypnotic (sleeping pill) is often a matter of dose— (SEE ALSO: Abuse Liability of Drugs; Drug Interac- lower doses act as sedatives and higher doses pro- tions and Alcohol; Drug Types; Suicide and Sub- mote sleep. stance Abuse) In some people, sedative-hypnotics can produce a paradoxical state of excitement and confusion. BIBLIOGRAPHY This tends to occur more frequently in the very GILMAN, A. G., ET AL.(EDS.). (1996). Goodman and young and older populations. Some of these drugs Gilman’s the pharmacological basis of therapeutics, have the potential to be abused. Very high doses of 9th ed. NewYork: Macmillan. most sedative-hypnotic drugs will produce general NEMEROFF,C.B.&SCHATSBERG,A.F.(EDS.). (1998). anesthesia and can depress respiration so much The American psychiatric press textbook of psycho- that breathing must be maintained artificially or pharmacology. Washington D.C.: American Psychiat- death will occur. The benzodiazepines are an ex- ric Press. ception to this in that higher doses typically pro- SCOTT E. LUKAS duce sleep and are far less likely to severely depress REVISED BY NICHOLAS DEMARTINIS respiration. One of the first agents to be added to the list of the classic sedatives (alcohol and opiates) was bro- SEDATIVES: ADVERSE CONSE- mide, introduced in 1857 as a treatment of epi- QUENCES OF CHRONIC USE Sedative lepsy. Chloral hydrate was introduced in 1869, and drugs are also called hypnotics or SEDATIVE-HYP- paraldehyde was first used in 1882. The barbitu- NOTICS. They are sometimes referred to as ‘‘minor rates were introduced in the early 1900’s and re- tranquilizers’’ or ‘‘anxiolytics’’ (antianxiety medi- mained the dominant drugs for inducing sleep and cations). Technically, a sedative decreases activity sedation until the bezodiazepines were developed in and calms, while a hypnotic produces drowsiness, the late 1950’s and early 1060’s. A number of allowing for the onset and maintenance of a state of miscellaneous non-barbiturate sedatives Sleep similar to natural sleep and from which the (ethchlorvynol, glutethimide, carbromal, sleeper may be easily awakened. The same drug methylparafynol, methprylon, methaqualone) used for sedation, pharmacologically induced were introduced in the 1940’s and 1950’s, and for a sleep, and general systemic anesthesia may be seen brief period rivaled the barbiturates in popularity, to induce a continuum of central nervous system but their used declined rapidly along with the use of (CNS) depression. Such drugs are usually referred barbiturates. The bromides were recognized to to, therefore, as sedative-hypnotics, and they are have toxic properties, but they were still in use until widely prescribed in the treatment of insomnia the mid-twentieth century; chloral hydrate and (sleep problems). Although some people take these paraldehyde were used well into the late 1970’s drugs only occasionally and for specific sleep problems (grief, time-limited stress, long-distance and are still used in some places. Some drugs with flights), many more take them over prolonged pe- other medical uses are prescribed as hypnotics, but riods (months and even years) as a presumed aid to the effectiveness of these substances remains to be nightly sleep. They do this despite medical advice proven in well-controlled clinical trials. to restrict such drugs to about two weeks of use. An advance in the development of sedative-hyp- All the sedatives are available in tablets or cap- notics occurred with the discovery of non-benzodi- sules for oral dosage, and some are also available azepine drugs that also act on the bensodiazepine for intravenous or intramuscular administration. receptor. Zolpidem and zaleplon are short acting Almost all sedatives have the same behavioral ef- hypnotics that demonstrate fewer side-effects and fects as alcohol (ethanol). Many persons who abuse less tendency for rebound insomnia when they are sedatives, are, or have been problem drinkers. Ac- discontinued, a common problem with the benzodi- cording to guidelines published by the American azepines. These drugs also demonstrate less abuse Psychiatric Association (1990), patients with a his- potential than many of the other sedative-hyp- tory of alcoholism or other drug abuse problems notics and little respiratory depression. should not be treated with benzodiazepine seda- 1020 SEDATIVES: ADVERSE CONSEQUENCES OF CHRONIC USE tives on a chronic basis because they are at high Classification. Benzodiazepines can be classi- risk of developing benzodiazepine abuse. fied on pharmacokinetic grounds into long-acting (e.g., flurazepam, diazepam [Valium], USE OF HYPNOTICS chlordiazepoxide [Librium]); medium-acting (temazepam) and short-acting (triazolam, Sleep problems in adults are of three main types oxazepam [Serax], lorazepam [Ativan]) sedative- (1) problems of falling asleep (sleep initiation), hypnotics. Their efficacy, at least in short-term use, (2) problems staying asleep (sleep maintenance), has been well documented. The pattern of improve- and (3) early-morning wakening. Sleep-onset ment in sleep corresponds fairly closely with the problems vary little with age; early-morning pharmacokinetic properties of each drug, pro- wakening is often secondary to depression; and viding that factors of absorption and elimination sleep-maintenance problems showa clear and are taken into account. For example, temazepam is marked increase with aging. Whereas approxi- absorbed relatively slowly and has little effect on mately 10 percent of young adults complain of sleep-initiation time, whereas triazolam is ab- serious sleep problems, this increases to 30 to 50 sorbed relatively rapidly, which brings sleep on percent of those aged seventy or older (Morgan, more quickly. 1990). Each sedative-hypnotic has a minimally effec- This age-related pattern for complaints of in- tive dose, but the dose that is usually effective may somnia is reflected in the pattern of use of sedative- be twice as high as the minimum. Further increases hypnotic drugs. For example, in the United States may, however, cause side effects and rebound in- 2.6 percent and in Britain 4 percent of adults take a somnia without substantially improving sleep. In benzodiazepine as a sleep inducer during any given sleep-laboratory studies, many benzodiazepines year (Mellinger, Balter, & Uhlenhuth, 1985; Dun- are found to lose their efficacy after about two bar et al., 1989). In the elderly, this increases to 16 weeks of nightly use. Subjectively, however, pa- percent use in a year, with 73 percent of those tients often feel that their sleep is improved for taking the drug regularly for a year or more. In- longer periods than this. deed, 4 percent of people older than 65 had used Adverse effects. Benzodiazepine sedatives the drug continuously for more than a decade have three major adverse effects: cumulative effects (Morgan et al., 1988). Across all age groups, with repeated dosage, particularly if the patient has roughly twice as many women as men take seda- not yet metabolized the previous dose; additive ef- tive-hypnotic drugs. fects when given with other classes of sedatives or The most commonly prescribed hypnotics in- with alcohol; and residual effects after the medica- clude several benzodiazepines: flurazepam tion is discontinued. Patients taking benzodiaze- (Dalmane), quazepam (Doral), temazepam (Re- pines may feel drowsy, have reduced psychomotor storil), and triazolam (Halcion). Other hypnotics speed, and impaired concentration. These in turn not related to the benzodiazepines are chloral hy- can adversely affect their ability to function; pa- drate (Noctec), a chloral derivative, and hy- tients should be cautioned about driving and oper- droxyzine (Vistaril), an antihistamine. ating machinery while taking these drugs. The longer-acting the drug, the more pronounced are BENZODIAZEPINES these effects. Tolerance to these sedative effects builds up to some extent over repeated use of the BENZODIAZEPINES remain by far the most fre- drug. Age-related changes in the way that drugs are quently used sedative-hypnotic drugs (although metabolized and excreted mean that benzodiaze- there are some newcompounds withdiffering pines accumulate more in older patients and, there- modes of action). The key concerns in the hypnotic fore, adverse effects are more pronounced in the use of the benzodiazepines are (1) adverse effects elderly. experienced while the patient is taking the drug; All benzodiazepines can impair the users ability (2) possible physical and psychological depen- to learn and remember newinformation. This dence; and (3) rebound insomnia and WITH- memory impairment is most pronounced a few DRAWAL symptoms when the patient stops taking hours after taking the drug, so when taken as a the drug. sleep aid, such effects may be much reduced by the SEDATIVES: ADVERSE CONSEQUENCES OF CHRONIC USE 1021 time the person wakes the next morning. Again, the humans, the benzodiazepines have reinforcing ef- elderly are particularly prone to such effects. As fects that appear to be more pronounced in fre- with other adverse effects, higher doses cause quent users of other recreational drugs. For exam- greater problems. Rarer adverse effects include dis- ple, alcoholics and HEROIN addicts will at times use inhibition and aggressive behavior. These effects benzodiazepines to eke out their supply of first- have been reported for some benzodiazepines (e.g., preference drug, since ALCOHOL and heroin are also triazolam, flunitrazepam) more than others. depressants. Rebound insomnia refers to the heightened in- Abuse of benzodiazepines by themselves is rela- somnia that may occur when the patient stops tak- tively unusual, but sometimes occurs among users ing the drug, such that the sleep pattern is actually who seek a ‘‘high’’ from massive amounts of these worse than it was before the medication. Studies drugs. Street drug dealers sell benzodiazepines at a have established that rebound insomnia is gener- relatively lowcost in most major cities. Some abus- ally at its worst following the shorter-acting benzo- ers combine benzodiazepines with other drugs to diazepines and its least following the longer-acting enhance the effects; for example, some believe that benzodiazepines (Roehrs et al., 1986). Rebound is taking diazepam half an hour after an oral dose of clearly dose-related, so the lowest effective dose methadone will produce a ‘‘high’’ that is more in- should be prescribed, with rebound effects de- tense than can be obtained from taking either drug scribed to warn the patient about overdosing for by itself. ‘‘faster’’ or ‘‘better’’ drug-induced sleep. Overdose. Overdosing on benzodiazepines is a Abuse, dependence and withdrawal. Some medical emergency. It is marked by respiratory argue that rebound insomnia is itself a sign of phys- depression, lowblood pressure, shock, coma, and iological dependence on benzodiazepine hypnotics eventual death. Flumanezil (Romazicon) is a ben- (e.g., Morgan, 1990). Others insist that dependence zodiazepine antagonist that can be given intrave- is shown only when withdrawal from a drug leads nously to reverse the sedative effects of an overdose. to symptoms other than a rebound of the original problems. In general, psychological dependence on OTHER SEDATIVE/HYPNOTIC DRUGS benzodiazepines can develop rather rapidly. After only a few weeks, patients who attempt to discon- Barbiturates. Barbiturates were used until the tinue the medication may experience restlessness, 1950s as sleeping pills but were superseded by the disturbing dreams, paranoid ideas and delusions, benzodiazepines. With the exception of phenobar- and feelings of tension or anxiety in the early morn- bital (Luminal), which is still used as a sedative ing. Withdrawal following moderate-dose usage and as an anticonvulsant, the barbiturates are may include dizziness, increased sensitivity to light rarely prescribed. and sound, and muscle cramps. Withdrawal fol- Chloral Derivatives. These compounds, lowing high-dose usage may result in seizures and which include chloral hydrate, are sometimes used delirium. with elderly patients since they are less likely to The syndrome of withdrawal from benzodiaze- cause restlessness in confused or demented pa- pines may be slowin onset because these drugs tients. They are also relatively safe to give to chil- remain in the body for relatively long periods. dren for sedation before or after surgery. Chloral Withdrawal appears to be most severe in patients derivatives can, however, cause gastric irritation who used benzodiazepines that are absorbed rap- and rashes. idly and have a rapid decline in blood serum levels Antihistamines. Diphenhydramine (alprazolam, lorazepam, and triazolam). In pa- (Benadryl, Nytol, Sominex) and hydroxyzine (At- tients who abused both benzodiazepines and alco- arax, Vistaril) are often prescribed for patients who hol, a delayed benzodiazepine withdrawal syn- need only a mild sedative. They are safe and do not drome may complicate withdrawal from alcohol. produce dependency. They should not, however, be Patients who are high-dose abusers of benzodiaze- used together with alcohol. The most common side pines usually require inpatient detoxification. effect of these medications is dry mouth. Abuse. Animal studies indicate that benzodi- Newer Medications. Newer compounds in- azepines, like cocaine and opioids, activate a brain clude such nonbenzodiazepine hypnotics as reward pathway in the brains of most mammals. In zopiclone and zolpidem (Ambien), which act either 1022 SEIZURES, BRAIN

atypically or selectively on benzodiazepine recep- MORGAN, K. (1990). Hypnotics in the elderly: What tors. They are chemically distinct from benzodiaze- cause for concern? Drugs, 10, 688–696. pines and from each other. Both are short-acting MORGAN, K., ET AL. (1988). Prevalence, frequency and drugs and at normal clinical doses cause little resid- duration of hypnotic drug use among the elderly liv- ual (hangover) sedation. The risk of rebound in- ing at home. British Medical Journal, 296, 601–602. somnia or dependence with these compounds is OSWALD, I. (1983). Benzodiazepines and sleep. In M. R. thought to be lowbut not absent (Lader, 1992). Trimble (Ed.), Benzodiazepines divided: A multidisci- Buspirone (BuSpar) is the only antianxiety med- plinary review. NewYork: John Wiley. ication that is not a sedative. Because it does not ROEHRS, T. A., ET AL. (1986). Dose-determinants of produce depressant effects or dependence, it is be- rebound insomnia. British Journal of Clinical Phar- ing used increasingly in the treatment of depression macology, 22, 143–147. as well as anxiety. Unlike the sedatives, buspirone WILSON, B. A., SHANNON, M. T., & STANG, C. L. (Eds.) does not affect the patient’s alertness or motor (1995). Nurses drug guide, 3rd ed. Norwalk, CT: skills, it does not intensify the effects of alcohol, Appleton & Lange. and it does not produce a withdrawal syndrome. VALERIE CURRAN REVISED BY REBECCA J. FREY (SEE ALSO: Accidents and Injuries from Drugs; Ad- diction: Concepts and Deﬁnitions; Aging, Drugs, and Alcohol; Barbiturates: Complications; Benzo- SEIZURES, BRAIN See Complications, diazepines: Complications; Drug Interaction and Neurological the Brain; Drug Interactions and Alcohol; Memory, Effects of Drugs on; Prescription Drug Abuse)

SEIZURES OF DRUGS The seizure of BIBLIOGRAPHY drugs is a salient consequence of a variety of U.S. BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck enforcement programs, but particularly of in- manual of diagnosis and therapy, 17th ed. terdiction. It provides evidence that the U.S. crimi- Whitehouse Station, NJ: Merck Research Laborato- nal-justice system is imposing costs on drug distri- ries. bution. A large seizure offers the most vivid DUNBAR, G., ET AL. (1989). Patterns of benzodiazepine evidence that senior members of the drug trades are use in Great Britain as measured by a general popula- subject to serious risks. tion survey. British Journal of Psychiatry, 155, 836– Seizures from smugglers have often been used as 841. a measure of the effectiveness of interdiction ef- EISENDRATH, S. J. (1998). Psychiatric disorders. In L. M. forts. One argument suggests that the larger the Tierney et al. (Eds.), Current Medical Diagnosis & quantity of drugs seized, the more smugglers have Treatment, 37th ed. Stamford, CT: Appleton & been hurt by interdiction. Others viewseizures as Lange. an indicator of the quantity smuggled; this view HARDMAN,J.G.,&LIMBIRD, L. E. (Eds.) (1996). Good- assumes that the share of imports seized is effec- man and Gilman’s the pharmacological basis of ther- tively a constant. Clearly these are extreme as- apeutics, 9th ed. NewYork: McGraw-Hill. sumptions. The quantity seized is a function of at LADER, M. H. (1992). Rebound insomnia and newer least three factors: the quantity shipped, the rela- hypnotics. Psychopharmacology, 108, 248–252. tive skill of the interdictors, and the care taken by LEARY, A., & MACDONALD, T. (2000). Interactions be- smugglers. The last element, given least attention tween alcohol and drugs. Edinburgh, UK: Royal Col- in discussion of seizures, probably depends on the lege of Physicians of Edinburgh. replacement cost of the drugs; if that cost goes MEDICAL ECONOMICS COMPANY. (1999). Physicians’ desk down (e.g., because of good growing conditions in reference, (PDR), 53rd edition. Montvale, NJ: Author. the producer country), smugglers will invest less in MELLINGER, G. D., BALTER, M. B., & UHLENHUTH,E.H. concealment and protection of shipments and thus (1985). Insomnia and its treatment. Archives of Gen- the seizure rate (i.e., the share of shipments seized) eral Psychiatry, 42, 225–232. is likely to rise. SENSATION AND PERCEPTION AND EFFECTS OF DRUGS 1023

drugs. In 1999, the ﬁgure had risen to 2.62 million pounds. Drugs are also seized by state and local police. Estimates are difﬁcult to calculate at these levels of lawenforcement, but it is believed that seizures at these levels have also grown during the 1990s. The growth of domestically grown marijuana has placed state and local police closer to the criminal activity. Likewise, the proliferation of domestic methamphetamine labs has made such facilities targets for both federal and state lawenforcement.

(SEE ALSO: Drug Interdiction; International Drug Supply Systems; Operation Intercept; Source Countries for Illicit Drugs)

BIBLIOGRAPHY

GODSHAW, J., KOPPEL, R., & PANCOAST, R. (1987). An- tidrug law enforcement efforts and their impact. MAGUIRE,K.&PASTORE, A.L. (eds.) (1998). Sourcebook of criminal justice statistics. Washington, DC: U.S. Government Printing Office. Pennsylvania National Guardsmen, with the help WHITE HOUSE OFFICE OF NATIONAL DRUG CONTROL POL- of spotters in a helicopter, found more than 80 of ICY. (2000). National drug control strategy: 2000 an- these marijuana plants growing in the middle of nual report. Washington, DC: U.S. Government a cornfield in York County, August 25, 1998. Printing Office. (AP Photo/Keith Srakocic) PETER REUTER REVISED BY FREDERICK K. GRITTNER

Seizures of COCAINE rose throughout the 1980s, probably reflecting both the rapid increase in total SELF-HELP AND ANNONYMOUS shipments and the declining replacement cost of GROUPS See Treatment Types the drug. In 1989, federal authorities seized over 218,000 pounds of cocaine and that figure continued to rise during the 1990s. In 1999, cocaine SENSATION AND PERCEPTION AND seizures reached almost 291,000 pounds. MARI- EFFECTS OF DRUGS Every behavior in JUANA seizures grewdramatically during the same which an organism engages involves information period. Federal authorities seized about 1.1 million from the primary senses, such as vision, hearing pounds in 1989 and by 1999 the figure reached 2.3 (audition), and touch. A number of drugs of abuse million pounds. This is largely the result of in- alter sensory information. Mind-altering drugs can creased U.S. cultivation and production of mari- also influence perception of time, thinking, behav- juana. Heroin seizures fluctuated between 1989 ior, and mood. Often abusers of these drugs experi- and 1999 but the overall trend was less dramatic ence severe depression, anxiety, paranoia, confu- than with other drugs. In 1989, federal authorities sion, and terror. seized 2,415 pounds of heroin; in 1999, 2,788 Naturally occurring drugs, such as MESCALINE pounds were seized. The total amount of drugs from the PEYOTE cactus, increase awareness of vi- seized during this period, which also includes hash- sual and auditory sensations and also produce vi- ish, almost doubled. In 1989, the federal govern- sual illusions and HALLUCINATIONS.The ment seized a total of 1.343 million pounds of PSILOCYBIN mushroom (Mexican or Magic mush- 1024 SENSATION AND PERCEPTION AND EFFECTS OF DRUGS room) produces similar effects. Because of these OBSERVATIONS IN HUMAN SUBJECTS sensory changes, mescaline and psilocybin have Most of our information about drugs and the been used since pre-Columbian times in religious ways in which they alter sensory behavior in people ceremonies by the peoples of Mexico and the Amer- comes from individual reports (called anecdotal) ican southwest. rather than from well-controlled laboratory stud- LYSERGIC ACID DIETHYLAMIDE (LSD), an artifi- ies. People have reported vivid images, changes in cially-produced drug which was first synthesized in perception, and hallucinations after they have the late 1930s by the Swiss chemist Albert Hoff- taken mescaline or LSD. Synesthesias—a mixing of mann, has become well known for producing in- the senses, such as ‘‘the hearing of colors’’ or ‘‘the tense and colorful visual sensations. People also seeing of sounds’’—may also occur. One of the first report changes in sensory behavior with drugs that descriptions of LSD’s effects is recounted as fol- are related to LSD (such as DMT, DOM, and lows: MDMA, also known as ‘‘ecstasy’’ or the ‘‘love I was seized by a peculiar sensation. . . . Objects, as drug’’). DMT is a short-acting (cycle takes less than well as the shape of my associates in the labora- one hour) crystalline powder that produces visual tory, appeared to undergo optical changes. . . . hallucinations. DOM, also known as STP, is more With my eyes closed, fantastic pictures of extraor- than 50 times as potent as mescaline. MDMA pro- dinary plasticity and intensive color seemed to duces ‘‘out-of-body’’ sensations and acts as a stim- surge toward me. After two hours this state gradu- ulant. PHENCYCLIDINE (PCP) is another synthe- ally wore off (Julien 180). sized drug that is sometimes added to the list of drugs that alter sensory behavior; however, its sen- Although these sensory disturbances stop within a fewhours, some people experience confusion, sory effects are limited to numbness in the hands sensory distortions, or poor concentration for and feet. Ketamine, also known as Special K, is a longer periods of time. For some people, drug ef- veterinary medicine that is chemically similar to fects recur long after the drugs have left their sys- PCP; its effects range from delirium to inability to tems—these brief episodes are called flashbacks. move. The active constituent of marijuana, STUDIES IN THE LABORATORY TETRAHYDROCANNABINOL (THC), also produces alterations in sensory behavior; however hallucina- Since alterations in sensory behavior, such as tions—such as those produced by mescaline or hallucinations, cannot be observed directly, it is LSD—are less common with THC, although there very difficult to examine these effects in laboratory is an increased risk of psychotic symptoms among animals. One way to investigate a drug’s effect on users with a family or personal history of psychosis. sensory behavior is to train animals to behave differently in the presence of different types of visual COCAINE and AMPHETAMINE sometimes produce hallucinations and other sensory distortions, but or auditory stimuli. If a drug changes the animal’s behavior, it is possible that these changes in behav- only when they are taken for long periods of time. ior are due to a change in howwellthe animal hears Various names are used to describe drugs that or sees the stimuli. Another type of procedure ex- alter sensory behavior. One term is psychedelic, amines howintense (e.g., howloud or howbright) a which refers to mind-expansion or to experiencing stimulus has to be for an organism to hear or see it. events that go beyond normal boundaries; this In these procedures, the intensity required to hear word was coined in 1956 by Humphrey Osmond, a or see a stimulus is determined before a drug is British psychiatrist. Another term is psychotomi- given and then it is compared to the intensity re- metic, which refer to the similarities of hallucina- quired to hear or see the stimulus after the drug is tions that occur in psychotic disorders, such as given. SCHIZOPHRENIA, and those produced by mescaline In general, drugs such as mescaline, LSD, and and LSD. The term hallucinogenic is slightly mis- THC do not alter an animal’s ability to tell the leading, since not all drugs that alter sensory be- difference between visual or auditory stimuli—nor havior produce hallucinations. do they alter visual or auditory thresholds. This SEROTONIN-UPTAKE INHIBITORS IN TREATMENT OF SUBSTANCE ABUSE 1025 lack of effect in animals suggests one of two expla- SENTENCES FOR DRUG OFFENSES nations: either drugs such as LSD produce different See Mandatory Sentencing; Shock Incarceration effects in animals than they do in people, or, more and Boot-Camp Prisons likely, the procedures that are used to study alterations in sensory behavior in animals do not measure the unique ways in which drugs such as LSD alter sensory behavior. SEROTONIN Chemically named 5-hydroxy- Conversely, MDMA testing has found compara- tryptamine, this MONOAMINE transmitter is a widely ble results in both animals and humans. A late distributed substance particularly prevalent in the 1990s study (conducted on red squirrel monkeys) gut, blood, platelets, and pineal gland, as well as in at Johns Hopkins University showed that MDMA nine major sets of brain neurons (nerve cells). In has damaging effects on memory. Published in the 1950s, chemical similarity between serotonin 2000, a British study of both current and previous and the chemical HALLUCINOGEN LYSERGIC ACID MDMA users has discovered both immediate and DIETHYLAMIDE (LSD) focused attention on this delayed memory deficits. NEUROTRANSMITTER in mental illness, a link strengthened by experimental studies in animals and humans. Neurons containing serotonin, a typi- (SEE ALSO: Complications; Inhalants; Opiates/Opi- oids; Research; Research, Animal Model ) cal monoamine, project widely throughout the brain and spinal cord, and a large number of well- characterized serotonin-receptor subtypes mediate BIBLIOGRAPHY both direct and indirect regulation of ion channels HARRIGAN, P. (1999). Are cannabis and psychosis that exist in the membranes of neurons. By regulat- linked? The Lancet, 353, 730. ing these channels, these serotonin RECEPTORS in- JAFFE, J. H. (1990). Drug addiction and drug abuse. In fluence the concentration within the neuron of such םם ם A. G. Gilman et al. (Eds.), Goodman and Gilman’s ions as K (potassium) and Ca (calcium) and the pharmacological basis of therapeutics, 8th ed. thereby the activity of the cell. NewYork: Pergamon. JULIEN, R. M. (1988). A primer of drug action. NewYork: (SEE ALSO: Brain Structures and Drugs; Dopamine; W. H. Freeman. Neurotransmission; Reward Pathways and Drugs; KAWASAKI,A.,&PURVIN, V. (1996). Persistent Serotonin-Uptake Inhibitors in Treatment of Sub- palinopsia following ingestion of lysergic acid distance Abuse) ethylamide (LSD). JAMA, The Journal of the Ameri- can Medical Association, 276, 432. BIBLIOGRAPHY KOWALSKI, K. M. (2000). What Hallucinogens Can Do to COOPER, J. R., BLOOM, F. E., & ROTH, R. H. (1991). The Your Brain. Current Health 2, 26, 6. biochemical basis of neuropharmacology, 6th ed. MONROE, J. (1998). The LSD story. Current Health 2, NewYork: Oxford University Press. 24, 24. SEYMOUR, R. B. (1999). The lunch-hour psychedelic: A FLOYD BLOOM 30-minute trip. Psychopharmacology Update, 10, 6. TAYLOR, E. (1996). Psychedelics: the second coming. Psychology Today, 29, 56. SEROTONIN-UPTAKE INHIBITORS IN WAREING, M., ET AL. (2000). Working memory deficits in TREATMENT OF SUBSTANCE ABUSE current and previous users of MDMA (‘ecstasy’). Brit- The development of effective pharmacological ish Journal of Psychology, 91, 181. treatments for alcohol and drug abuse depends on LINDA DYKSTRA our understanding of the biological mechanisms REVISED BY REBECCA MARLOW-FERGUSON that start and maintain these behaviors. Studies in animals and humans have confirmed that SEROTO- NIN is one of several NEUROTRANSMITTERS that in- SENSATION SEEKING See Vulnerability fluence drug-reinforcing behaviors. Pharmacologi- as Cause of Substance Abuse cal agents that enhance central serotonergic 1026 SEROTONIN-UPTAKE INHIBITORS IN TREATMENT OF SUBSTANCE ABUSE neurotransmission—in particular, serotonin- The observation that serotonin-uptake inhibi- uptake inhibitors (several of which have been mar- tors decrease desire to drink indicates a possible keted as antidepressants)—showconsiderable mechanism of their effects on alcohol intake. In the promise, as of the early 1990s, as effective treat- outpatient trials, an increase in abstinent days was ments for the abuse of alcohol and some other often the means by which alcohol intake was re- drugs. These work by blocking the re-uptake of duced, and similarly, in trials with animals, seroto- serotonin and thereby increase its concentration in nin-uptake inhibitors decreased their number of the nerve SYNAPSE. drinking ‘‘bouts.’’ Therefore, serotonin uptake inhibitors may, by decreasing the desire to drink, ALCOHOL ABUSE reduce the likelihood of initiating drinking. The consistency of the pharmacological effects is quite In the late 1980s, serotonin-uptake inhibitors remarkable, considering the many other factors in- were tested in various animal models of alcohol- fluencing drinking behavior. In an effort to enhance ism—including selectively bred alcohol-preferring the pharmacological effects of serotonin-uptake in- rats given a choice between water and an alcohol solution—and showed consistent decreases in the hibitors and determine their therapeutic value, a self-administration of alcohol in a dose-dependent brief psychosocial intervention was combined with manner. The results of these preclinical studies led citalopram in a long-term (12 week) treatment re- to research in human alcohol abusers. In four search study with sixty-two mildly/moderately de- placebo-controlled, double-blind, randomized pendent alcoholics. Average decreases in daily alco- clinical trials, serotonin-uptake inhibitors de- holic drinks from baseline were 47.9 percent ס creased short-term (1 to 4 weeks) alcohol intake by during the first week of citalopram (n 31) and averages of 14 to 20 percent, as compared with only 26.1 percent during the first week of placebo ס pretreatment. No other treatment or advice was (n 31), indicating a significant improvement given. The effect developed rapidly after a seroto- with citalopram. From the second to twelfth weeks nin-uptake inhibitor was administered and disap- of treatment, the average decreases were similar: peared rapidly after discontinuation. All subjects 33.4 percent and 40.5 percent during citalopram had had mild or moderate (not severe) alcohol de- and placebo, respectively. Craving for alcohol also pendence but no current or past depression, anxi- decreased similarly with both citalopram and ety, other psychiatric disorder, or other substance- placebo. Thus, the short-term effects of citalopram abuse disorder. No aversive interactions with alco- are synergistic with a brief psychosocial interven- hol or changes in depression or anxiety levels were tion, and serotonin-uptake inhibitors seem to facili- observed; therefore they could not account for the tate the initiation of reduced drinking. The true effects on alcohol intake. Adverse side effects were therapeutic value of serotonin-uptake inhibitors is fewand mild. However,concomitant decreases in yet to be determined, but they may be appropriate desire/urge to drink were reported by subjects dur- for specific applications. For example, relapse is a ing treatment with serotonin-uptake inhibitors. frequent problem among recovering alcoholics; se- Therefore, experimental drinking sessions, follow- rotonin-uptake inhibitors, by decreasing desire or ing one or two weeks of treatment with serotonin- urge to drink, may be particularly suitable adjuncts uptake inhibitor and placebo, were incorporated for relapse-prevention strategies. into two research studies—fluoxetine (Prozac) and citalopram, each with a placebo control—to specif- COCAINE ically measure variations in self-reported desire to drink alcohol. Desire for alcohol was lower during Abuse of COCAINE increased in the 1980s; it is the experimental drinking sessions after taking se- also common among HEROIN addicts—some who rotonin-uptake inhibitors than after taking use it alone and some together with heroin. Fluoxe- placebos. In both of these studies, the effects of tine decreased cocaine craving and abuse in some serotonin-uptake inhibitors on alcohol intake were heroin addicts who were in a METHADONE MAINTE- also confirmed in the outpatient weeks preceding NANCE PROGRAM. These interesting results merit the experimental drinking sessions. further study in a controlled trial. SHANGHAI OPIUM CONFERENCE 1027

CIGARETTE SMOKING rently no evidence that serotonin uptake inhibitors reduce cigarette smoking or opiate abuse. Cigarette smoking has not been affected by serotonin-uptake inhibitors in heavy drinkers who were not trying to reduce their smoking. Fluoxetine was BIBLIOGRAPHY found to prevent the weight gain that accompanies GORELICK, D. A. (1989). Serotonin uptake blockers and smoking cessation and, therefore, may be helpful in the treatment of alcoholism. In M. Galanter (Ed.), preventing relapse among exsmokers. The results Recent developments in alcoholism, vol. 7. NewYork: of studies on the use of serotonin-uptake inhibitors Plenum. in patients participating in smoking-cessation pro- NARANJO,C.A.&BREMNER, K. E. (1991). Recent trends grams have not been reported yet. in the pharmacotherapy of drug dependence. Drugs of Today, 27, 479–495. PSYCHIATRIC DISORDERS NARANJO, C. A., & SELLERS, E. M. (1989). Serotonin uptake inhibitors attenuate ethanol intake in problem Individuals who abuse alcohol and/or drugs of- drinkers. In M. Galanter (Ed.), Recent developments ten have psychological or psychiatric disorders. in alcoholism, vol. 7. NewYork: Plenum. The establishment of cause-and-effect relation- CLAUDIO A. NARANJO ships can be difficult. There is evidence that KAREN E. BREMNER comorbidity (two disease processes) adversely influences outcome in treatments of substance abuse. Some patients may self-medicate symptoms of ANXIETY or DEPRESSION with a drug of abuse, such SEXUAL AND PHYSICAL ABUSE See as alcohol. Therefore, successful pharmacological Vulnerability as Cause of Substance Abuse treatment of the anxiety or depression may reduce the need for other drugs (the alcohol). As antidepressants, serotonin-uptake inhibitors SHANGHAI OPIUM CONFERENCE The would be particularly suitable for treating de- 1909 Shanghai Opium Commission was the first pressed substance abusers. No research studies multinational drug-control initiative. Through the have been conducted, but a comparison between encouragement of President Theodore Roosevelt treatment outcomes of depressed substance abus- and the organizational skills of Bishop Charles H. ers receiving a serotonin-uptake inhibitor and Brent, the United States convened this meeting of those receiving other antidepressants would be of thirteen countries at Shanghai, including Great interest. Britain, Japan, China, and Russia, to address the Severe cognitive deficits (memory loss) are a illegal production, trade, and use of OPIUM in frequent complication of chronic ALCOHOLISM. China. Lowbrain levels of serotonin may be a factor in this As a commission the participants could only type of memory loss. Fluvoxamine, a serotonin- recommend actions necessary to prevent opium uptake inhibitor, improved episodic memory in pa- trafficking and abuse but could not make binding tients with alcohol amnestic disorder. This might international agreements. However, the partici- greatly facilitate success in cognitively oriented pants passed resolutions urging national govern- treatments for alcoholism. ments to enact measures to curb opium smoking in their countries, initiate regulation of opium use for nonmedical purposes, ban the export of opium to CONCLUSIONS countries that prohibited importation, and control Serotonin-uptake inhibitors decrease short-term the manufacture and distribution of opium alcohol intake and desire to drink. Their effects are derivatives. synergistic with a brief psychosocial intervention The commission was the first effective step taken for alcoholism; however, their long-term efficacy by the international community to combat drug and clinical importance have not been determined. abuse. It served as a catalyst for countries to pass One small study indicated that a serotonin-uptake domestic legislation addressing drug problems inhibitor may reduce cocaine abuse. There is cur- within their borders. Most important, the commis- 1028 SHOCK INCARCERATION AND BOOT-CAMP PRISONS sion united countries in an international coopera- other prisoners. They are allowed few personal pos- tive effort to address the problem of the opium sessions, no televisions, and infrequent visits from trade. The work of the commission led to the con- relatives on the outside. vening of the Hague Opium Conferences (1912– The correctional officers in the programs are re- 1914) and to the adoption of the 1912 Interna- ferred to as drill instructors and are responsible for tional Opium Convention, sometimes called the seeing that the inmates obey the rules and partici- Hague Opium Convention, and succeeding treaties pate in all activities. When speaking to staff, in- that effectively restricted opium production and mates must refer to themselves as ‘‘this inmate’’ trade to legitimate purposes. and they must proceed and followeach sentence with sir or madam as in ‘‘Sir, yes, sir.’’ Disobedi- (SEE ALSO: Asia, Drug Use in; International Drug ence is punished immediately using summary pun- Supply Systems; Opioids and Opioid Control: His- ishments, frequently in the form of some additional tory; Psychotropic Substances Convention of 1971; physical activity, such as pushups or situps. More Single Convention on Narcotic Drugs) serious rule violations may result in dismissal from the program. BIBLIOGRAPHY BOOT-CAMP PRISONS AS BEAN, P. (1974). The social control of drugs. NewYork: INTERMEDIATE SANCTIONS Wiley. KING, R. (1992). The drug hang-up: America’s fifty-year The boot-camp prisons were developed during folly. NewYork: Norton. the 1980s—in part, in response to the phenomenal MUSTO, D. F. (1973). The American disease: Origins of growth in the number of convicted offenders. Cor- narcotic control. NewHaven: Yale University Press. rectional jurisdictions faced severe prison overcrowding, and probation caseloads grew so large ROBERT T. ANGAROLA that many offenders received only nominal supervi- ALAN MINSK sion during their time in the community. Officials searched for ways to manage the offenders. There were two options—either they were sent to prison SHOCK INCARCERATION AND BOOT- or they were supervised in the community on pro- CAMP PRISONS Shock incarceration probation. Neither option was entirely satisfactory for grams, frequently called boot-camp prisons, are the large number of young offenders. Alternative short-term prison programs run like military basic sanctions or intermediate punishments such as in- training for young offenders—adult and youthful tensive community supervision, house arrest, or felons (MacKenzie & Parent, 1992). Boot-camp residential-community corrections centers were prisons were first established in Georgia and Okla- proposed as solutions to the problem. These options homa in 1983 and since then all states and many provided more control than a sentence to probation counties have adopted this type of program. Boot- but less than a sentence to prison. Boot-camp pris- camp prisons have proved controversial over time, ons were one relatively inexpensive alternative as critics argue that this type of regimen does not sanction that became particularly popular. reduce recidivism (the tendency to return to crime). The first boot-camp prisons were begun in 1983, In the late 1990s, allegations of misconduct and in Oklahoma and Georgia. These two programs abuse by boot-camp prison staff members against attracted a great deal of attention and other juris- their juvenile inmates have led to criminal investi- dictions soon began developing similar programs. gations and the closing of facilities. Nevertheless, By 1999, more than fifty boot camps housed about this type of ‘‘tough love’’ approach remains a popu- 4,500 juveniles. Additional facilities house adult lar option for correctional officials. felons and other programs have been started in Those sentenced to boot-camp prisons are re- local jails and in juvenile-detention centers. Al- quired to arise early each day to participate in a though the majority of the boot camps have male rigorous schedule of physical training, military drill participants, some programs admit women into the and ceremony, and hard labor. While they are in boot camps with the male offenders. Other states the boot camp, participants are separated from have developed completely separate boot-camp SHOCK INCARCERATION AND BOOT-CAMP PRISONS 1029 prisons for women. The Federal Bureau of Prisons rest while waiting to be served. They stand at atten- developed one boot camp for males and a separate tion until ordered to sit and eat without conversa- program for females. However, by 2000 several tion. Following breakfast they may work six to states had either ended their programs or drastic- eight hours. This is usually hard physical labor ally scaled back the size of the programs. such as cleaning state parks or public roads. They return in the late afternoon for additional physical ENTERING AND EXITING exercise or practice in drill and ceremony. After a quick dinner, they attend rehabilitation programs Since most boot camps have strict requirements until 9 P.M. when they return to their dormitories. about who is eligible for the camp, inmates are In the short period before bedtime, they have time carefully evaluated prior to being sent there. Most to be sure their shoes are shined and their clothes programs require participants to sign an agreement are clean and ready for the morning. saying they have volunteered. They are given information about the program and the difference be- SIMILARITIES AND DIFFERENCES tween a boot-camp prison and a traditional prison. The major incentive for entering the boot camp is All the boot-camp prisons incorporate the core that the boot camp requires a shorter term than a components of military basic training, with physi- traditional prison sentence. cal training and hard labor. Most target young The first day of the boot camp involves a difficult offenders convicted of nonviolent crimes such as in-take process, when the drill instructors confront drug, burglary, or theft. Participation is limited to the inmates. Inmates are given rapid orders about those who do not have an extensive past history of the rules of the camp, when they can speak, how criminal activity. they are to address the drill instructors, and howto Other than these similarities, the programs dif- stand at attention. The men have their heads fer dramatically. Some focus only on work, military shaved; the women receive short haircuts. This drill, and exercise. In other boot camps, offenders early period of time in the boot camp is physically spend a great deal of time each day in rehabilitation and mentally stressful for most inmates. programs. The camps also differ in the type of the The programs last from 90 to 180 days. Those therapeutic programming provided. Some empha- dismissed prior to graduation are considered pro- size academic education, others focus on group gram failures. They are either sent immediately to a counseling or treatment for substance abuse. traditional prison to serve a longer term of incar- The boot camps also differ in the ways offenders ceration or they are returned to court for are managed after release. Some programs inten- resentencing. sively supervise all offenders who successfully com- Offenders who successfully complete the boot plete the boot camp; others are supervised as they camp are released from prison. After graduating, would be in traditional probation caseloads. Pro- offenders are supervised in the community for the gram officials worry about the difficulty the gradu- rest of their sentence. There is usually an elaborate ates have in making the transition from the rigid graduation ceremony when inmates demonstrate structure of the boot camps to the community envi- the military drills they have practiced. Many pro- ronment. For this reason, some boot camps devel- grams encourage family members to attend the oped aftercare programs to help them make the graduation ceremony. change. These aftercare programs do more than increase the surveillance over the activities of the A DAY IN BOOT CAMP graduates. They are designed to provide drug treatment, vocational counseling, academic education, On a typical day, the participants arise before or short-term housing to boot-camp graduates. dawn, rapidly dress, clean their living quarters, and march in cadence to an exercise area. There they DRUG TREATMENT IN THE will spend an hour or more doing calisthenics and BOOT CAMPS running. They march back to their quarters for a quick cleanup before breakfast. As they do at every The earliest boot camps focused on discipline meal, they march to breakfast and stand at parade and hard work. More recently, they have begun to 1030 SHOCK INCARCERATION AND BOOT-CAMP PRISONS

New York’s Therapeutic Community Boot Camps. In the boot camps that include substance-abuse treatment as a component of the in-prison phase of the program, there are large differences in the way it is delivered. The boot- camp programs, developed by the NewYork De- partment of Correctional Services, use a therapeutic-community model for the program. All offenders are given a similar regimen of drug treatment while they are incarcerated (New York Department of Correctional Services, 1994). Each platoon in the boot camp forms a small community. They meet daily to solve problems and to discuss their progress in the shock program. They spend over 200 hours during the six-month program in substance-abuse treatment activity. The treatment is based on the ALCOHOLICS ANONYMOUS (AA) and NARCOTIC ANONYMOUS (NA) models of abstinence and recovery. All boot camp inmates participate in the substance-abuse treatment regardless of their history of use and abuse. Illinois’s Boot Camp with Levels of Treat- ment. Like NewYork, the Illinois boot camp also targets substance abusers. However, the delivery of treatment services is very different. In Illinois, Participants in the Sumter County Correctional counselors at the boot camp evaluate offenders and Institution ‘‘boot camp’’ program arrive at their match the education and treatment level to the barracks in Bushnell, Florida, July 9, 1989. identified severity level of the offender (Illinois De- (᭧ Bettmann/CORBIS) partment of Corrections, 1992). Three different levels of treatment are provided. Inmates identified as level-one have no substance-abuse history, emphasize treatment and education. It became therefore they receive only two weeks of education. clear that many of the entrants were drug-involved. Level-two inmates are identified as probable sub- Realizing that the punishment alone would not ef- stance abusers. They receive four weeks of treat- fectively reduce the drug use of these offenders, ment in addition to the drug education. The treat- corrections officials introduced drug treatment or ment consists of group therapy focusing education into the daily schedule of boot-camp ac- predominately on denial and on family-support is- tivities. By the late 1980s, all the camps had some sues. Inmates identified as level-three are consid- type of substance-abuse treatment or education for ered to have serious drug addictions; they receive boot-camp inmates (MacKenzie, 1994). ten weeks of education and treatment. In addition As happened with other aspects of the programs, to the drug education and group therapy, they re- the type of treatment and the amount of time de- ceive group sessions on substance-abuse relapse, voted to substance-abuse treatment varied greatly CODEPENDENCY, behavioral differences, family addiction, and roles within the family. among programs. The 90-day Florida program in- Texas’s Voluntary Participation Model. A cluded only 15 days of treatment and education; in third model is represented by the Texas program contrast, in the NewYork program all offenders (MacKenzie, 1994). In the boot camp, all partici- received 180 days of treatment. Most programs pants receive five weeks of drug education. During reported that drug use was monitored during com- this phase, inmates may also receive individual munity supervision; however, the schedule and fre- counseling and attend Twelve-Step fellowship quency of this monitoring varies greatly. meetings. More drug treatment is available for SHOCK INCARCERATION AND BOOT-CAMP PRISONS 1031 those who volunteer (the substance-abuse coun- In interviews, offenders who are near graduation selors in this program believe that treatment should from boot camp report that they are drug free and be voluntary). These volunteers receive approxi- physically healthy (MacKenzie and Souryal, 1994). mately four hours per week of treatment in the Unlike offenders incarcerated in conventional pris- form of group therapy. The meetings are held dur- ons, boot-camp participants believed that their exing free time, so inmates are not released from work perience had been positive and that they had to attend. The group sessions focus on social values, changed for the better. They also reported that the self-worth, communication skills, self-awareness, reason they entered the boot camp was because family systems, self-esteem, and goal setting. Some they believed they would spend less time in inmates also receive individual counseling. prison—not because of the treatment or therapy offered. DISMISSAL RATES PERFORMANCE DURING As occurs in many drug-treatment programs, COMMUNITY SUPERVISION boot camps may have high dismissal rates. De- pending upon the program, rates vary from 8 per- Studies have compared the performance during cent (Georgia in 1989) to as much as 80 percent community supervision of graduates from the boot- (Wisconsin in 1993). Offenders can be dismissed camp prisons to others who served a longer time in from the boot camp because of misbehavior or, in prison or who were sentenced to probation. In most some boot camps, they can voluntarily ask to leave. cases, there were no significant differences between Those who are dismissed will either be sent to a these offenders in recidivism rates or in positive traditional prison, where they will serve a longer social activities (MacKenzie & Souryal, 1994). sentence than the one assigned to boot camp, or However, boot-camp graduates in Illinois and Lou- isiana had fewer revocations for new crimes. Re- they will be returned to the court for resentencing. search examining NewYork offenders found mixed Thus, in both cases there is the threat of a longer results. Graduates had fewer new crime revocations term in prison for those who do not complete the in one study (NewYork Correctional Services, boot camp. 1994) and fewer technical violations in another There is very little information about howdrug- study (MacKenzie & Souryal, 1994). involved offenders do in boot camp prisons. One All the boot-camp prisons had a military atmo- study of the Louisiana boot camp examined the sphere with physical training, drill and ceremony, dismissal rates of drug-involved offenders and and hard labor. If this atmosphere alone changed compared these rates to offenders in the boot camp offenders, we would expect all the graduates to who were not identified as drug-involved (Shaw & have lower recidivism rates and better positive ad- MacKenzie, 1992). Two groups of drug-involved justment. The inconsistency of the results suggests offenders were examined: (1) those who had a legal that the boot-camp atmosphere alone will not suc- history of drug-involvement (an arrest or convic- cessfully reduce recidivism or positively change of- tion for a drug offense); and (2) those who were fenders. Some other aspects of the Illinois, New identified as drug abusers on the basis of self-re- York, and Louisiana programs, either with or with- port. In this program, offenders were permitted to out the boot-camp atmosphere, led to the positive drop out voluntarily or they could be dismissed for impact on these offenders. After an examination of misbehavior. Surprisingly, in comparison to other these programs, the researchers concluded that all offenders, the drug-involved offenders were less three programs devoted a great deal of time to ther- likely to drop out of the program. apeutic activities during the boot-camp prison, a In another study of the Louisiana boot camp, 20 large number of entrants were dismissed, the length percent of the participants were identified as prob- of time in the boot camp was longer than other boot lem drinkers on the basis of their self-reported camps, participation was voluntary, and the alcohol use and problems associated with use in-prison phase was followed by six months of in- (Shaw& MacKenzie, 1989). The problem drinkers tensive supervision in the community. Research as were no more likely to drop out of the book-camp of the mid-1990s cannot separate the effect of these prison than were the others. components from the impact of the military atmo- 1032 SHOCK INCARCERATION AND BOOT-CAMP PRISONS sphere. Most likely, a critical component of the boot People are concerned that inmates’ rights will camps for drug-involved offenders is the therapy not be observed and that they are being coerced to provided during the program and the transition do something that is not good for them (Morash & and aftercare treatment provided during commu- Rucker, 1990). These critics argue that the sum- nity supervision. mary punishments and the staff yelling at offenders Performance of Drug-Involved Offenders. may be abusive for inmates; that participants may Shawand MacKenzie (1992) studied the perform- leave the boot-camp prison angry and damaged by ance of drug-involved offenders during community the experience; that the military atmosphere de- supervision in Louisiana. In comparison to of- signed to make a cohesive fighting unit may not be fenders who were not drug-involved, those who appropriate for these young offenders. These con- were drug-involved did poorer during community cerns became public in the late 1990s, as state and supervision. This was true of those on probation, federal prosecutors investigated allegations of parolees from traditional prisons, and parolees abuse and misconduct by prison camp staff. Mary- from the boot camp. The boot-camp parolees did land fired its top five juvenile-justice officials in not do better than others. During the first year of 1999 after state officials investigated reports of sys- supervision, the drug-involved offenders were more tematic assaults at three boot-camp prisons. likely to have a positive drug screen. Advocates of the boot camp say that the pro- Problem drinkers who graduated from the Loui- gram has many benefits. In their opinion, these siana program were found to perform better, as offenders lack the discipline and accountability measured by positive activities during community that are provided by the program. Furthermore, supervision (Shaw& MacKenzie, 1989). Their per- they argue, the strong relationship between the of- formance was, however, more varied—indicating fenders and the drill instructors may be helpful to that they may need more support and aftercare the inmates. Also, there may be some aspects of the than other offenders. boot camps that are particularly beneficial for In contrast to the Louisiana findings, research in drug-involved offenders. Although controversy ex- New York indicated that those who were returned ists about the boot-camp prisons, they remain a to prison were more apt to be alcoholics (New York popular alternative sanction. Department of Correctional Services, 1994). In both Louisiana and New York, offenders who were (SEE ALSO: Civil Commitment; Coerced Treatment convicted of drug offenses did better than self- for Substance Offenders; Narcotic Addict Rehabili- confessed alcoholics during community supervi- tation Act; Prisons and Jails; Treatment in the Fed- sion. eral Prison System; Treatment Types: An Over- view) THE FUTURE OF BOOT-CAMP PRISONS BIBLIOGRAPHY

Boot-camp prisons are still controversial. By the ANGLIN,M.D.,&HSER, Y-I. (1990). Treatment of drug late 1990s, skepticism rose about the effectiveness abuse. In M. Tonry & J. Q. Wilson (Eds.), Drugs and of this approach. Studies conducted for the U.S. crime: Vol. 13, Crime and justice. Chicago: University Justice Department found that the national recidi- of Chicago Press. vism rate for boot camps ranged from 64 to 75 ILLINOIS DEPARTMENT OF CORRECTIONS. (1991). Overview percent. This compared to recidivism rates from 63 of the Illinois Department of Corrections impact in- to 71 percent for those who served their time in carceration program. Springﬁeld, IL: Author. traditional detention centers. Though juveniles of- MACKENZIE, D. L. (1994). Shock incarceration as an al- ten responded well while in the camps, they re- ternative for drug offenders. In D. L. MacKenzie & turned to the same neighborhoods where they ﬁrst C. D. Uchida (Eds.), Drugs and crime: Evaluating got into trouble. Colorado, North Dakota and Ari- public policy initiatives. Thousand Oaks, CA: Sage. zona ended their programs and Georgia, where MACKENZIE, D. L., & PARENT, D. G. (1992). Boot camp boot-camp prisons started, is phasing out its prisons for young offenders. In J. M. Byrne, A. J. camps. Lurigio, & J. Petersilia (Eds.), Smart sentencing: The SINGLE CONVENTION ON NARCOTIC DRUGS 1033

emergence of intermediate sanctions. London: Sage eight multilateral treaties aimed at preventing the Publications. illicit trade and consumption of opium and other MACKENZIE, D. L., & SOURYAL, C. (1994). Multi-site drugs. Over forty years, many of the provisions had evaluation of shock incarceration: Executive sum- become obsolete, had never been implemented, or mary. Report to the National Institute of Justice. required revision as world developments presented Washington, DC: National Institute of Justice. newchallenges. The Single Convention consoli- MARKS, A. (December 27, 1999). States fall out of dated the existing multilateral drug-control treaties (tough) love with boot camps. The Christian Science into one agreement. Its drafters also intended to Monitor. encourage governments that had not participated MORASH, M., & RUCKER, L. (1990). A critical look at the in earlier drug-control agreements to join the inter- ideal of boot camp as a correctional reform. Crime national effort. As of November 1993, 144 govern- and Delinquency, 36, 204–222. ments were party to the Single Convention. NEW YORK STATE DEPARTMENT OF CORRECTIONAL SER- VICES AND THE NEW YORK DIVISION OF PAROLE. (1993). PROVISIONS OF THE The fifth annual shock legislative report. Albany, NY: SINGLE CONVENTION Unpublished report by the Division of Program Plan- ning, Research and Evaluation and the Office of Pol- The Single Convention contains eight major pro- icy Analysis and Information. visions for the control of the production, trade, and use of drugs. All parties must establish or adjust SHAW, J. W., & MACKENZIE, D. L. (1992). The one-year community supervision performance of drug of- national legislation to conform to these requirements of the convention. fenders and Louisiana DOC-identified substance Parties must require licenses for manufacturers, abusers graduating from shock incarceration. Journal wholesalers, and other handlers of narcotic drugs, of Criminal Justice, 20, 501–516. and they must maintain a system of permits, record SHAW, J. W., & MACKENZIE, D. L. (1989). Shock incar- keeping, reports, controls, and inspections to pre- ceration and its impact on the lives of problem drink- vent diversion of drugs to the illicit traffic. A coun- ers. American Journal of Criminal Justice, 16, 63–97. try that allows the domestic production of the SOURYAL, C., & MACKENZIE, D. L. (1994). Shock ther- OPIUM poppy, the COCA bush, or the Cannabis apy: Can boot camps provide effective drug treat- plant must establish a control agency to designate ment? Corrections Today, 56(1), 48–54. areas for the cultivation of these drugs and limit WEST, W. (April 3,2000). Civilian boot camps lack in- production to licensed growers. tended kick. Insight on the News v16 i13 p.48. Parties to the convention must prepare estimates DORIS LAYTON MACKENZIE (quotas) detailing the amount of drugs necessary to REVISED BY FREDERICK K. GRITTNER satisfy national medical and scientific needs, and they must provide these figures annually to the International Narcotics Control Board (INCB). SIDE EFFECTS See Complications Governments must also provide the INCB with quarterly and annual statistics on drug production, trade, and consumption. In addition, the Single SINGLE CONVENTION ON NARCOTIC Convention requires that parties maintain a system DRUGS The Single Convention on Narcotic of import and export authorizations as well as im- Drugs of 1961 is the most comprehensive interna- port certificates so that the INCB and governments tional drug control agreement ever signed. It regu- can monitor the flowof narcotics in and out of lates the production, trade, and use of NARCOTIC countries. drugs, COCAINE, and cannabis (MARIJUANA). The Single Convention extends the control system over the opium poppy to the coca bush and the cannabis plant. Governments must uproot and BACKGROUND destroy wild and illegally cultivated coca bushes Thirteen countries signed the first international and cannabis plants. Parties are furthermore re- drug control treaty in 1912 at The Hague, Nether- quired to ban opium smoking and eating, coca- lands. Into the 1950s, governments entered into leaf chewing, and cannabis smoking and ingestion. 1034 SINGLE CONVENTION ON NARCOTIC DRUGS

A transition period is provided to overcome any The Single Convention strengthens the role of difficulties that might arise for those who use such the United Nations Commission on Narcotic Drugs plants or drugs in ancient rituals. Countries may (CND). The CND, which is composed of fifty gov- reserve the right to permit the quasi-medical use ernments, is the UN body that is the key informa- of opium and coca leaves as well as the tion and policymaker in the drug-control area. The nonmedical use of cannabis. CND adds and deletes substances to or from the The Single Convention encourages parties to four control schedules of the convention, notifies provide assistance and treatment to drug addicts. the INCB of drug-control concerns, recommends This provision distinguishes the agreement from ways to curb the illicit traffic of narcotics, and previous international drug-control treaties, which notifies nonparticipants of the actions that have focused exclusively on curbing the illicit flowof been taken. It also gathers the names of the author- drugs. ities that issue licenses for import and export.

INTERNATIONAL NARCOTICS DRUG SCHEDULES CONTROL BOARD AND COMMISSION In the preamble to the Single Convention, the ON NARCOTIC DRUGS parties recognized that ‘‘the medical use of narcotic Signatories to the Single Convention recognized drugs continues to be indispensable for the relief of the need for an international central monitoring pain and suffering and that an adequate provision and enforcement agency to oversee the production must be made to ensure the availability of narcotic and trade of drugs. The Single Convention merged drugs for such purposes.’’ In an effort to make the Permanent Central Opium Board and the Drug narcotic drugs available for legitimate medical use Supervisory Board into the INCB, which serves as while also curtailing drug abuse, the parties placed narcotic drugs into four schedules. Classification of this central authority. The United Nations Eco- a narcotic drug and the type of regulation that nomic and Social Council elects thirteen members would be imposed on that drug substance would to serve on the INCB. depend on a drug’s potential for abuse as well as its The main responsibilities of the INCBs include medical benefit. limiting the cultivation, production, manufacture, Schedule I is reserved for medically useful drugs and use of narcotic drugs and psychotropic sub- exhibiting the highest potential for abuse. Exam- stances to the amounts necessary for medical and ples of schedule I drugs include OPIUM,MORPHINE, scientific purposes, ensuring the availability of and METHADONE. these drugs for medical purposes such as pain con- Schedule II substances possess a liability for trol. The INCB reviews estimates of opium and abuse that is no greater than that of CODEINE. These other drug-production figures provided by each drugs are placed under similar controls as schedule I party. These figures are formalized into production substances except that parties need not require and consumption quotas. The board also analyzes prescriptions for domestic supply. Medical practi- information from participating countries, the tioners are not required to keep records tracking the United Nations, and other international organiza- acquisition and disposal by individuals of a con- tions to ensure that there is compliance with the trolled substance placed in schedule II. Codeine is terms of the Single Convention. Where appropriate, the most commonly prescribed schedule II drug. it recommends that technical and financial assis- Drugs in schedule III are the ones intended for tance be given to those countries that may need medical use that, as prepared, pose a negligible or further help. The Single Convention also provides nonexistent risk of abuse and a lowpublic health the INCB with some direct enforcement powers, risk. Schedule III drugs face substantially fewer such as recommending an embargo of drug ship- controls than those listed in schedules I and II. ments to a country that is a center of drug traf- Preparations of codeine and the analgesic dex- ficking. The INCB is more effective, however, in tropropoxyphene are two examples of drugs listed encouraging government to comply through confi- in schedule III. dential diplomatic initiatives than through the im- To place a drug in schedules II and III govern- position of sanctions. ments must control the factories where these drugs SINGLE CONVENTION ON NARCOTIC DRUGS 1035 are manufactured as well as the individuals in- emphasizes the prevention of drug abuse, the dis- volved in their manufacture, trade, distribution, tribution of drug information and education, and and import or export. Records of the manufacture the treatment and rehabilitation of drug addicts. It and sale of these drugs must be maintained, and also stresses the need to balance legitimate produc- limits must be imposed to ensure that they are used tion of narcotics for medical and scientific purposes exclusively for medical and scientific purposes. with prevention of illicit production, manufacture, The special class of drugs in schedule IV exhibit traffic, and use of these substances. strong addiction-producing properties or a high liability of abuse that cannot be offset by medical THE SIGNIFICANCE OF THE benefits or that poses too great a risk to public SINGLE CONVENTION health to hazard using them commonly in medical practice. Drugs in this category remain subject to The Single Convention has proved important in the same international controls that are applicable four ways. First, the aims, goals, and strategy in to schedule I drugs, but governments are encour- regard to combatting illicit drug trafficking became aged to limit their legitimate use. Cannabis, canna- more focused and modernized because of its adop- bis resin, and heroin (diamorphine) are examples tion. Second, the large number of participants in of schedule IV drugs. Several medical experts have the Convention encourages more countries to take questioned the appropriateness of limiting the use part in the international cooperative effort against of diamorphine for pain control and a number of drug abuse. Third, the placement of drugs into governments permit this use. schedules constitutes a recognition of the differ- Note that these schedules or levels of control ences between drug substances, and it balances the differ from those contained in the Controlled Sub- potential for abuse of the drugs with their medical stances Act (CSA) of the United States. For exam- benefit. The Single Convention, which openly supple, in this act, drugs with a high liability for abuse ports the medical use of narcotics to relieve pain and no accepted medical uses are included in and suffering, states that these drugs are ‘‘indis- Schedule I. The CSA also covers all categories of pensable’’ for the purpose. Narcotics with a higher drugs including sedatives, HALLUCINOGENS, and potential for abuse and with a lower medical value cocaine besides other stimulants, whereas the Sin- fall subject to tighter regulation than drugs with a gle Convention covers only opioid drugs, cocaine, lower potential for abuse and a greater medical and cannabis (marijuana). Other psychoactive value. Fourth, the international community appre- drugs with abuse potential are controlled under a ciates the need to combine strict controls of illicit different international treaty, the Convention on drug trafficking with the treatment and rehabilita- Psychotropic Substances of 1971. tion of drug addicts. This approach, fusing strength The World Health Organization (WHO) is re- with compassion, is now an integral part of the sponsible for making recommendations regarding effort to curb the illicit production, trade, and con- the scheduling of drugs. In evaluating the schedule sumption of narcotic drugs. of a drug, WHO considers the ‘‘degree of liability to abuse’’ of a substance and the ‘‘risk to public health EE ALSO: International Drug Supply Systems; and social welfare’’ that the substance in question (S poses or might pose. The Convention grants WHO Opioids and Opioid Control: History; Psychotropic broad discretion in interpreting these two criteria. Substances Convention of 1971; Shanghai Opium Ultimately, the Commission on Narcotic Drugs de- Conference; World Health Organization Expert cides, by majority vote, whether to alter or amend a Committee on Drug Dependence) schedule, thereby reserving the right to reject WHO’s recommendation. BIBLIOGRAPHY

BEAN, P. (1974). The social control of drugs. NewYork: THE 1972 PROTOCOL Wiley. The 1972 Protocol Amending the Single Con- BRUUN, K., PAN, L., & REXED, I. (1975). The gentlemen’s vention on Narcotic Drugs confers greater powers club: International control of dungs and alcohol. Chi- on the International Narcotics Control Board and cago: University of Chicago Press. 1036 SKID ROW

CHATTERJEE, S. K. (1981). Legal aspects of international acid [a shortening of d-lysergic acid di- drug control. The Hague: Martinus Nijhoff. ethylamide; since about 1960] LSD INTERNATIONAL NARCOTICS CONTROL BOARD. (1993). Adam [originally named to connote a primordial U.N. Publication No. E.94.X1.2. NewYork: United man in a state of innocence] MDMA, a mild Nations. hallucinogen. See ecstasy below KING, R. (1992). The drug hang-up: America’s fifty-year amp [from ampule—the drug is sold in small folly. NewYork: Norton. glass ampules, which are broken open and the REXED, B., ET AL. (1984). Guidelines for the control of contents inhaled] amyl nitrite, a dilator of narcotic and psychotropic substances. Geneva: World small blood vessels and used in medicine for Health Organization. angina pains; used illicitly to intensify orgasm SINGLE CONVENTION ON NARCOTIC DRUGS. (1961). 18 or for the stimulation effect U.S.T. 1407, T.I.A.S. No. 6298. March 30. amps amphetamines SINGLE CONVENTION ON NARCOTIC DRUGS OF 1961, angel dust [since the 1970s] phencyclidine (a AMENDMENTS. (1972). 26 U.S.T. 1439, T.I.A.S. No. brand name is Sernyl), an anesthetic used on 8118. March 25. animals but originally on humans; discontin- WISOTSKY, S. (1986). Breaking the impasse in the war on ued because of bizarre mental effects. See PCP drugs. Westport, CT: Greenwood Press. below WORLD PEACE THROUGH LAW CENTER. (1973). Interna- bagging taking an inhalant by breathing it from tional Drug Control (prepared for the Sixth World a bag Conference of the Legal Profession, sponsored in part base the pure alkaloid of cocaine that has been by the U.S. Department of Justice). Washington, DC: extracted from the salt (cocaine hydrochlo- Author. ride), in the form of a hard white crust or rock. ROBERT T. ANGAROLA See crack and rock below batu crystalline methamphetamine beamed up [from ‘‘Beam me up, Scotty,’’ an SKID ROW See Homelessness, Alcohol, and expression used in the television series Star Other Drugs, History of Trek; Scotty is also a term for crack cocaine; on a mission means looking for crack] intoxi- SKIN DAMAGE AND DRUGS See cated by crack Complications: Dermatological beamer a crack addict beans dextroamphetamines beast LSD SLANG AND JARGON Slang terms in the beat [from the idea of beating—cheating— drug subculture are constantly changing, as its eth- someone] a bogus or mislabeled drug or a nic, social, and demographic composition changes substance resembling a certain drug and sold and as newillicit drugs roll in and roll out withthe as that drug (soap chips as crack; metham- tides of fashion, including geographical variations. phetamine or baking soda as cocaine; catnip as Yet certain terms showa remarkable durability marijuana; PCP as LSD, mescaline, or tetra- such as some of those for heroin (trademarked hydrocannabinol (THC)—the active principle Heroin in Germany, 1898)—a narcotic that has of marijuana; procaine as cocaine) been a staple street anodyne since the early 1900s. big H heroin Other drug-related terms have come into the big C cocaine mainstream to become a permanent part of the blank nonpsychoactive powder sold as a drug English language, e.g., yen, hooked, pad, spaced black beauties amphetamines out, high, and hip. Many of the following words black tar heroin had been in use during much of the twentieth cen- blast a drag of crack smoke from a pipe tury (a fewantiques of sociological or historical blotter [doses of the drug are dripped on a sheet interest are included) and some are the product of of blotter paper for sale] LSD the 1980s and 1990s. Origins, if known, are given. blow (1) to sniff a drug (2) cocaine (3) to smoke a amphetamines, a stimulant marijuana (‘‘blowa stick’’) a-bomb, bomb LSD, a hallucinogen blue heavens methaqualone (a sedative) pills SLANG AND JARGON 1037 bone a marijuana cigarette; a joint cocoa puff [pun on the name of a chocolate- boom marijuana flavored breakfast cereal] a joint, to which boomers hallucinogenic mushrooms containing cocaine has been added psilocybin coke cocaine booze alcohol cola [a word play on coke, cocaine, and Coca- bottles vials or small containers for selling crack Cola, cocaine is derived from the coca (not the boy heroin kola) plant] cocaine breakfast cereal ketamine. See K below cold turkey [from the gooseflesh that is part of brown heroin from Mexico diluted with brown abrupt withdrawal] by extension, ending a milk sugar (lactose), which is less pure than drug habit without medicinal or professional China white. Also called Mexican mud help, ‘‘going cold turkey’’ brown sugar heroin coming down [from a high] losing the effects of buds [from the appearance] marijuana or a drug, all the way down to crashing sinsemilla (a hybrid variety of marijuana; see connect [from the connection, a drug pusher] sinse); a quantity for sale consisting mainly of cocaine importer or wholesaler, who fronts the more potent flowering tops of the mari- (consigns) cocaine to a supplier, who in turn juana plant (Cannabis sativa) distributes to a street retailer. See dealing, bump (1) cocaine. (2) crack. (3) fake crack. mule, runner, steerer, touting (4) hit of ketamine. See K below. cop [from British slang of the 1700s; to obtain, to bush [from the righteous bush] marijuana steal, to buy; since the 1890s] to get or pur- bust [from 1930s Harlem slang for a police raid, chase illicit drugs perhaps a shortening of busting in] arrest cop a buzz get high button [from the shape of the appendages to the copping zone an area where drugs are sold peyote cactus containing mescaline] peyote or crack [from the crackling sound when smoked in San Pedro cactus a pipe] pebbles of cocaine base that are buzz, buzzed [from buzz, onomatopoeic equiva- smoked lent of subjective feeling; the onset of the drug crack house house or apartment (sometimes, an sometimes causes buzzing in the ears] (1) high abandoned building) where crack-cocaine is on marijuana. (2) an inferior high from heroin C cocaine sold and smoked on the premises 24/7— candy cocaine twenty-four hours a day, seven days a week caps hallucinogenic mushrooms crank crystal methamphetamine chalk [from the appearance] crystal metham- crank lite [from crank, because of the amphet- ם phetamine or cocaine amine-like stimulant effect lite, meaning Charlie cocaine lighter, as in low-alcohol beer] ephedrine, a chasing the dragon [from a Chinese expression stimulant used in nonprescription medicines for inhaling fumes of heroin after heating it; as a decongestant, which is lighter than am- the melting drug resembles a wriggling snake phetamines or dragon] (1) inhaling heroin fumes after the crash, crashing to come all the way down from a substance is heated on a piece of tinfoil. drug high (2) smoking a mixture of crack and heroin cross roads [from the scored cross on the ta- cheba marijuana blets] amphetamines China white [from China (Indochina) white or crystal [in powder form] methamphetamine or heroin; since the 1970s] cocaine ס white stuff (1) relatively pure heroin from Southeast Asia. crystal supergrass marijuana with PCP (2) analogs of fentanyl (Sublimaze), an opioid cut to add adulterants to a drug—extending it to more potent than heroin and sold on the street make more money in selling it (some adulter- as China white ants are relatively harmless, some toxic) chipping, to chippy using heroin occasionally, date rape drug Rohypnol, called roofies. avoiding addiction Women at parties may have this tasteless, chronic marijuana odorless drug slipped into their drink. After 1038 SLANG AND JARGON

they lose consciousness, they may be raped nogenic drug synthesized from methampheta- and later have no memory of the incident. mine and resembling mescaline and LSD in deadeye blank stare produced by an overdose of chemical structure phencyclidine (PCP) or other drug eightball an eighth of an ounce of cocaine dealing [from dealer, a person who sells drugs; elephant tranquilizer PCP since the 1920s] selling drugs of all kinds Emilio [as in Emilio and Maria (Mary), from designer drugs synthetic compounds or drug Mary Jane] marijuana analogs that produce the effects of certain reg- energize me give me some crack ulated drugs but have slight differences in equalizer pebbles of crack-cocaine chemical composition to evade the regulatory Eve [variant of Adam, MDMA or ecstasy] MDE, law; e.g., analogs of fentanyl (China white); a mild hallucinogen derived from amphet- analogs of amphetamine and methampheta- amine. Adam and Eve is a compound of MDEA (n-ethyl-MDA or ס MDE ם mine such as MDA, MDMA (ecstasy), TMA, MDMA -dioxy-N-ethylam ם MMDA, MDE (Eve), MBDB; and toxic by- 3,4,methylene products of the synthetic opiate meperidine phetamine) (Demerol) such as MPTP and MPPP exing taking ecstasy dexies dextroamphetamines fix (1) a needed drug dose to hold off withdrawal ditch veins on the inside of the arm at the elbow, (2) a shot of heroin. See shoot below a site for injecting heroin. See tracks below flake [from the appearance] (1) cocaine hydro- do drugs take or use illicit drugs chloride (2) the sediment off a rock or chunk doobie a marijuana cigarette; a joint of cocaine dope [from Dutch doop, sauce (from dopen,to Flying Saucers [trade name] hallucinogenic dip). In the late nineteenth century, the term seeds of a variety of morning glory came to be applied to opium, a black gum forget pill Rohypnol. See roofies below shaped into pellets and smoked in a pipe] freebase [the psychoactive alkaloid, the base, (1) drugs (2) marijuana (3) heroin and other has been freed or extracted from the cocaine illicit drugs (4) intoxicating fumes of airplane hydrochloride] (1) crystals of pure cocaine. fuel, glue (5) Coca-Cola (2) to prepare the base; to smoke it dope fiend [opprobrious term for narcotic and frost freak one who inhales the fumes of Freon, a illicit drug users since the early 1900s; the coolant gas, to get high term is used ironically by drug users to defy funky green luggage a supply of marijuana in the social stigma] drug user, drug abuser, drug one’s baggage addict G gamma-hydroxybutyrate. See GHB below dosing slipping a hallucinogenic drug into GHB gamma-hydroxybutyrate; clear liquid, punch, brownies, etc., so that it will unwit- white powder, tablet, or capsule often com- tingly be consumed by others bined with alcohol; used mainly by adolescents drag to drawor pull on smoke from a cigarette, and young adults, often at nightclubs and pipe, or other item, ‘‘to take a drag’’; to convey raves. GHB is usually abused either for its that smoke into one’s throat and lungs. See intoxicating/sedative/euphoriant effects or for toke below its growth hormone-releasing effects, which drop to swallow LSD or a pill can build muscles. dugie, doojee [phonetic] heroin gangster marijuana dust PCP ganja [from gaja, Hindi word for India’s potent dusting (1) mixing either cocaine with tobacco in marijuana, consisting of the flowering tops and a cigarette or mixing heroin or opium with leaves of the hemp plant, where most of the marijuana or hashish in a joint. (2) smoking psychoactive resin is concentrated] marijuana PCP garbage can drug user who takes anything, ev- ecstasy, extacy [from the euphoria, heightened erything, combinations sensuality, intensified sexual desire attributed Georgia gamma-hydroxybutyrate. See GHB be- to the drug experience] MDMA (methylen- low edioxymethamphetamine), a mildly halluci- ghost LSD SLANG AND JARGON 1039 girl cocaine hit (1) an injection of a narcotic. (2) a snort of glass crystalline methamphetamine cocaine. (3) a drag from a crack pipe. (4) a gluey one who inhales glue fumes toke of marijuana. (5) to adulterate (cut)a barbiturates, and drug. (6) a dose of LSD ס goofing [from goofballs from goof, to act silly, stupidly, heedlessly] hog [from its original use as a veterinary anes- under the influence of barbiturates thetic] phencyclidine (PCP) grass marijuana chopped up line for smoking, home boy gamma-hydroxybutyrate. See GHB which looks like dried grass above green [harvested hemp leaves that are not prop- hooch alcohol erly cured; also, the lower leaves of the hemp horse heroin plant, which contain a smaller proportion of hot shot a potent dose of heroin sufficient to kill; the psychoactive resin] (1) marijuana of low heroin laced with cyanide potency, e.g., Chicago green. (2) ketamine, an huff to inhale ordinary household products to get anesthetic similar to phencyclidine (PCP) but high. Users huff directly from the container or milder in its effects, which is sprinkled on from inhalant-soaked rags, socks, or rolls of parsley or marijuana and smoked toilet paper. Inhalants include model airplane grievous bodily harm gamma-hydroxybu- glue, nail polish remover, cleaning fluids, hair tyrate. See GHB above spray, gasoline, the propellant in aerosol H heroin; also Big H whipped cream, spray paint, fabric protector, hash, hashish the concentrated resin of the mar- air conditioner fluid (freon), cooking spray ijuana plant, containing a high percentage of and correction fluid. ice extremely pure and addictive smokable form the active principle, tetrahydrocannabinol of crystalline methamphetamine (THC). J, jay [from joint] a marijuana cigarette hash oil liquid extracted from hashish, pro- jelly babies or beans amphetamine pills viding a more potent dose of the active princi- joint [from joint as part of paraphernalia for ple and more easily transported in vials. It injecting narcotics—particularly the needle; produces more sedation and deeper states of since the 1920s] a marijuana cigarette reverie than does hashish jonesing [after John Jones, the British physician Henry, Harry heroin who first described opiate withdrawal in 1700] herb [used to connote a benign natural sub- withdrawal from addiction; by extension, stance] marijuana craving any drug herbal ecstasy herbal combinations marketed as juice steroids a ‘‘natural high’’ that can be legally purchased Julio marijuana. See Emilio and Mary Jane over the counter in drug stores, music stores, junk [from junker, a pusher or peddler; since the and other shops. The active ingredients in- 1920s. Also possibly from a word for opium— clude caffeine and ephedrine. a play on junk, a Chinese boat—which was high [from the sense of euphoria, being above it later extended to all narcotics] heroin (which all, detached from unpleasant reality] intoxi- is derived from opium) cated by a drug K, super K, special K, Vitamin K ketamine, an hip [from laying (on) the hip, to smoke opium— anesthetic similar in structure to PCP. First the addict lay on his side on a pad in an synthesized by a pharmaceutical company in opium den—hence an opium user and then the early 1960s, powdered ketamine emerged extended to illicit drug users. In the alienated as a recreational drug in the 1970s. It became subculture of the jazz scene of the 1930s and Vitamin K in the underground club scene in 1940s, using drugs was expected and made the 1980s and Special K in the 1990s rave one keenly informed or hip—originally hep— scene. until ‘‘squares’’ adopted the word] sophisti- keester plant [from keester, rump, and plant,to cated, knowing, ‘‘in’’; possessing taste, knowl- place] drugs in a rubber container or condom edge, awareness of the newest, and a lifestyle concealed in the rectum superior to that of conventional people Ketaject, Ketalar ketamine. See K above 1040 SLANG AND JARGON kick the gong (around) to smoke opium (espe- hanced self-awareness, and increased sensitiv- cially in a Chinese opium den) itytomusic,art,andnature;also kick the habit [related to kick it out—to suffer synesthesia—cross-sensations, such as withdrawal symptoms, which include muscle ‘‘seeing’’ music or ‘‘hearing’’ colors spasms in the legs and kicking movements Miss Emma morphine from hyperactive reflexes in the spinal cord] monkey on one’s back desperate desire for (1) abrupt withdrawal from a drug to which drugs; addiction; craving one is addicted. (2) to conquer drug depen- moon [from the shape of slices of the bud of the dence peyote cactus] peyote kif marijuana moonrock heroin mixed with crack for smoking killer joints marijuana with PCP Moroccan candy [majoun (Arabic) is candy kind buds potent marijuana. See buds above laced with hashish, sold in Morocco, Afghani- LA coke ketamine. See K above stan] hashish. See hash above la roche Rohypnol. See roofies below mud heroin lady cocaine mule (1) a low-level drug smuggler from Latin laughing gas nitrous oxide America; mules often swallow a condom filled lid [from the nowobsolete practice of selling a with cocaine to be delivered at a destination— measure of marijuana in a pipe tobacco tin] an a dangerous practice called bodypacking. ounce of marijuana, usually sold in a plastic (2) heroin bag new Ecstasy ketamine. See K above line (1) a thin stream of cocaine on a mirror or night train PCP other smooth surface, which is sniffed through nose candy cocaine a quill—a rolled matchbook cover, tube, opium den [from den, an animal’s lair. The term straw, or tightly rolled dollar bill, etc. (2) a was coined by Westerners in nineteenth-cen- measure of cocaine for sale tury China, to have lurid connotations] a place liquid ecstasy gamma-hydroxybutyrate. See where opium is smoked. Chinese laborers GHB above brought the practice of smoking opium to luding out [from ludes, short for Quaaludes (a America during the gold rush of 1849 and the brand name for methaqualone, an addictive sedative)] taking methaqualone. 1850s and the building of the transcontinental Lyle [from lysergic acid] LSD railroad magic mushrooms hallucinogenic mushrooms ozone PCP mainline [from main line, a major rail route; pad [from the mats in opium dens on which the since the 1920s] (1) the large vein in the arm; smokers reclined and slept. In the 1930s, Har- the most accessible vein. (2) v. to inject mor- lem apartments where marijuana was sold and phine, heroin, or cocaine into any vein smoked while reclining on couches or mat- Mary Jane, MJ, Aunt Mary marijuana tresses were called tea pads] (1) private place MDMA ecstasy for taking drugs; a variant is crash pad,a meth methamphetamine place for recovering from the effects of a meth- microdot acid amphetamine run (period of extended use); Mexican brown marijuana from Mexico the user collapses (crashes) into an exhausted Mexican mud brown heroin from Mexico. See sleep. (2) by extension, since the 1950s, any brown above dwelling place, room, apartment mind altering the claimed mental effects of hal- PCP [from PeaCe Pill] phencyclidine (brand lucinogenic drugs—altered or intensified name Sernyl), a veterinary anesthetic that in- states of perception duces bizarre mental states in humans mind expansion [related to psychedelic, peace pill PCP mindmanifesting; a descriptive term for hallu- pearls [medical nickname] amyl nitrite ampules cinogenic drugs coined in the 1960s] the Persian white fentanyl. See China white above claimed mind-altering effects of hallucino- p-funk, p-dope [p stands for pure] fentanyl. See genic drugs, including greater spirituality, en- China white above SLANG AND JARGON 1041

PG paregoric, a traditional diarrhea remedy con- used in combination with alcohol and other taining opium. drugs. piece hashish, a form of marijuana. See hash rope Rohypnol. See roofies above above runner a messenger (often a juvenile) who de- pill popping [from popping something into livers drugs from the seller to the buyer (not to one’s mouth] promiscuous use of amphet- be confused with a drug runner, a smuggler) amine and barbiturate pills or capsules. One rush the quick initial onset of orgasmic sensa- who does this is a popper and may be a gar- tions—of warmth, euphoria, and relaxation bage can after injecting or inhaling heroin, cocaine, or pit veins on the inside of the arm at the elbow, a methamphetamine main site for injecting heroin and the place to scag heroin look for tracks. See ditch above schoolboy (1) codeine, a derivative of opium pop to inject. See shoot below with relatively low potency, used as a cough poppers [the glass ampule is popped open and suppressant and analgesic. (2) morphine the contents inhaled] amyl nitrite ampules Scotty crack-cocaine. See beamed up above pot [from potaguaya, a Mexican-Indian word for script prescription for a drug, often forged by marijuana] marijuana addicts psychedelic heroin ketamine. See K above script doctor a physician who will provide a pusher [extension from pusher—a person who drug prescription for a price—or one who is circulates counterfeit money; since the 1920s] deceived into providing one drug seller, drug dealer. See dealing above shabu crystalline methamphetamine quas, quacks [from Quaalude, a brand name of shake [the mixture is made by shaking the drug methaqualone] methaqualone pills, an addic- and the adulterant] (1) cocaine adulterated tive sedative (cut) with a harmless substance such as Raoul cocaine mannitol. (2) loose marijuana left at the bot- rave an all-night underground party, usually fre- tom of a bag that held a pressed block of quented by teens and college students. Raves marijuana. are characterized by techno music and often sheet (acid) [from decorated blotter paper con- designer drugs, especially Ecstasy. taining doses of the drug] LSD reds, red birds [also called red devils, red jack- shit heroin ets, red caps—from the color of the capsules] shoot inject a drug; also shoot up a fix or a shot Seconal (a brand of secobarbital) capsules (usually of heroin) reefer [from grifa, a Mexican-Spanish word for shooting gallery place where heroin addicts marijuana] (1) a marijuana cigarette. shoot up and share needles and other works (2) marijuana (paraphernalia) rhoids steroids shoot the breeze inhale nitrous oxide (called rib Rohypnol. See roofies below laughing gas). righteous bush marijuana plant shrooming high on hallucinogenic mushrooms ringer [from the idea of ‘‘hearing bells’’; bells is a shrooms hallucinogenic mushrooms term for crack] powerful effect from a hit of Sid a play on the s-d sound of LSD crack sinse [from sinsemilla, without seeds] a hybrid roach [from its resemblance to a cockroach] the variety of marijuana; also called ses butt (end) of a marijuana cigarette skin popping [from pop, to inject] injecting rock [from the appearance](1) large crystals or a heroin or any psychoactive drug subcutane- chunk of pure cocaine hydrochloride. ously (rather than into a vein), a practice of (2) crack. See base above casual (chippy) users. rocket fuel PCP skunk marijuana roofies, rophies, ruffies, roach, R2, roofenol smack [perhaps from shmek, Yiddish word for Rohypnol, the brand name for the powerful sniff, whiff, pinch of snuff; since the 1910s, sedative flunitrazepam. The pills are often when heroin users sniffed the drug; in the 1042 SLANG AND JARGON

1920s and 1930s, some Jewish mobsters were tooies [from Tuinal, a brand name for a prepara- involved in heroin trafficking] heroin tion containing amobarbital and secobarbital] smoke marijuana sedative capsules snappers [the ampule containing the drug is toot (1) to sniff cocaine. (2) cocaine. (3) a binge, snapped open] amyl nitrite capsules especially a drinking bout or spree (since the snob [from the idea of an elite—expensive— late 1700s) drug] cocaine. touting (1) purchasing drugs for someone else. snop marijuana (2) advertising, hawking, drugs that one is snort to sniff a drug selling snow [from the appearance; also, the drug is a tracks a line of scabs and scars from frequent topical anesthetic and numbs the mucous intravenous injections. See pit and ditch membranes] cocaine hydrochloride. above snowbirds cocaine tripping [from trip, in the sense of a psychic soapers [from Sopor, the brand name of a seda- ‘‘journey’’] taking LSD tive, nowtaken off the market] methaqualone trips (1) LSD tablets (2) periods under the influ- pills ence of various drugs, usually hallucinogens space basing or space blasting smoking a mix- turkey [from turkey, a jerk; or from a theatrical ture of crack and phencyclidine (PCP) failure or flop] (1) a nonpsychoactive sub- speed (1) amphetamines (2) caffeine pills stance sold as a drug. (2) the seller of such (3) diet pills phony substances speedball [first used by GIs during the Korean turn on take drugs, especially hallucinogens War] injected mixture of heroin and cocaine. ups, uppers amphetamines splif a fat marijuana cigarette V, Vs Valium (a brand name for diazepam, a spook heroin tranquilizer) tablets squirrel a mixture of PCP and marijuana sprin- wasted [from waste, a street-gang term since the kled with cocaine and smoked 1950s, meaning to kill, beat up, destroy] stash extension of stash, hobo argot for hiding (1) severely addicted to the point of mental place; since the 1800s (1) hiding place for and physical depletion (2) extremely intoxi- drugs. (2) a supply of drugs. (3) v. to hide cated—out of it, beyond caring drugs weed marijuana steerer member of a cocaine or heroin crewwho whack (1) to adulterate heroin, cocaine, or other directs people to the seller drugs. (2) an adulterant (3) phencyclidine stepped on adulterated or cut (PCP). (4) to kill stick a marijuana cigarette whiff [from the idea of smelling or shiffing] co- street drugs drugs purchased from sellers on the caine street; hence, of dubious quality white or white stuff heroin strung out severely addicted white beanies amphetamines sugar cubes LSD white lady, white [from the color] cocaine sunshine [from the type sold as an orange-col- window pane [the drug is sometimes sold in a ored tablet] LSD clear plastic square; also of a greater potency, super grass [the powder is sometimes mixed providing a more intense experience and non- with parsley or marijuana and smoked] keta- structured sensations—‘‘opening a window on mine. See green. reality’’] LSD tabs [from tablet, a form in which the drug is wired (1) extremely intoxicated by cocaine. sold] LSD (2) anxious and jittery from stimulants (may tea marijuana be related to amped, a play on amphetamines Thai stick potent marijuana from Thailand and amperes) thing (1) heroin. (2) pl. an addict’s works—the woola [phonetic spelling] a joint containing a hypodermic needle (needle and syringe) mixture of marijuana and crack tic [from THC] fake tetrahydrocannabinol works equipment or paraphernalia for injecting toke a drag on a marijuana cigarette drugs SLEEP, DREAMING, AND DRUGS 1043

X, the X, XTC [from ecstasy] MDMA. WENTWORTH,H.&FLEXNER, S. B. (1968). The pocket yellow jackets [from the color of the capsules] dictionary of American slang. NewYork: Pocket Nembutal brand of pentobarbital Books. yen [from English slang yen-yen, the opium WILLIAMS,TERRY. (1989). The cocaine kids. NewYork: habit, based on Cantonese in-yan (in, opium Addison-Wesley. ם yan, craving); since the 1800s] any strong RICHARD LINGEMAN craving REVISED BY MARY CARVLIN zenes [short for Thorazine, a brand name for chlorpromazine] tranquilizer pills zombie (1) crack cocaine. (2) phencyclidine SLEEP, DREAMING, AND DRUGS The (PCP) use of ‘‘mind-altering’’ drugs and intoxicating zooted up high on crack-cocaine drinks to hasten the onset of sleep and to enhance the experience of dreaming is a worldwide phenom- (SEE ALSO: Argot; Yippies) enon and goes back to prehistory. The ancient Greeks used hallucinatory substances for religious BIBLIOGRAPHY purposes. The priestesses at Delphi, for example, chewed certain leaves while sitting in a smoke-ﬁlled EISNER, B. (1989). Ecstasy: The MDMA story. Berkeley: chamber and going into a trance. On returning to Ronin. consciousness, they would bring forth a divine HURST, G., & HURST, H. (1981). The international drug prophecy. The various Dionysian cults encouraged scene. Wurzburg, Germany. their celebrants into ecstatic dream-like states INDIANA PREVENTION RESOURCE CENTER. (2000). On-line through the use of wine and perhaps other drugs dictionary of street drug slang, http://prc- (Cohen, 1977). wwwserv.idap.indiana.edu:80/slang/home.html. The ancient Hindus imbibed a sacred drink JULIEN,ROBERT M. (1992). A primer of drug action, 6th called ‘‘soma,’’ and MARIJUANA was used in prac- ed. NewYork: W. H. Freeman. tices of meditation. For the Arabs, HASHISH (a form LINGEMAN, R. (1974). Drugs from a to z, 2nd ed. New of marijuana) was the substance of choice, while York: McGraw-Hill. the Incas chewed the leaves of the COCA plant (from MENCKEN, H. L. (1967). The American language, which COCAINE may be made). The OPIUM poppy abridged with new material by Raven I. McDavid Jr. was used in Asia, and the ancient Mexicans used a NewYork: Knopf. variety of powerful PSYCHOACTIVE substances, in- NATIONAL CLEARINGHOUSE FOR ALCOHOL AND DRUG cluding PEYOTE, sacred mushrooms, and seeds INFORMATION (NCADI), U.S. DEPARTMENT OF HEALTH from the Mexican MORNING GLORY plant, to enter &HUMAN SERVICES. (2000). http://www.health.org/. the realm of dreams. The Australian aboriginals NATIONAL INSTITUTE ON DRUG ABUSE (NIDA), UNITED used the pituri, a psychoactive substance, to take STATES NATIONAL INSTITUTES OF HEALTH (NIH). them into ‘‘dream time,’’ as they referred to it. (2000), http://www.nida.nih.gov/NIDAHome2.html. Belladonna and OPIATES have historically been PARTNERSHIP FOR A DRUG-FREE AMERICA, (2000). Drug- used for the speciﬁc purpose of producing vivid free resource net, http://www.drugfreeamerica.org/ dreams. The most famous illustration is the story of PARTRIDGE,ERIC. (1961). A dictionary of the the English poet Samuel Taylor Coleridge (1772– underworld. NewYork: Bonanza. 1834), who allegedly wrote his most celebrated SEYMOUR, R. B., & SMITH, D. E. (1987). Guide to psycho- work, ‘‘Kubla Khan,’’ during a drug-induced active drugs: An up-to-the minute reference to mind- dream (Cohen, 1977). LYSERGIC ACID DI- altering substances. NewYork: Harrington Park ETHYLAMIDE (LSD) became popular in the United Press. States and Europe during the 1960s for ostensibly SPEARS, R. A. (1986). The slang and jargon of drugs and facilitating higher states of consciousness and crea- drink. Metuchen, NJ: ScarecrowPress. tivity. The writer John Lilley used a sensory-depri- UNITED STATES OFFICE OF NATIONAL DRUG CONTROL POL- vation tank to emulate the state of sleep while tak- ICY (2000). http://www.whitehousedrugpolicy.gov/ ing LSD to induce creative dreaming (Cohen, prevent/prevent.html. 1977). 1044 SLEEP, DREAMING, AND DRUGS

Reference to the effects of drugs and ALCOHOL that drugs affecting REM will also affect the freon sleep and dreaming are also found in popular quency and nature of dreams. literature. It was a mixture made from poppies that The effects of ethanol (alcohol) on sleep are caused Dorothy and her companions to fall into complex and somewhat paradoxical. The acute deep sleep in the Wizard of Oz (Baum, 1956). After bedtime administration of ethanol to healthy, non- ingesting a series of pills and liquids, in Through alcoholic volunteers shortens the latency to sleep the Looking Glass, Alice finds herself in ‘‘Wonder- onset and, depending on dose, may initially in- land,’’ where she has a conversation with an crease the amount of relaxed, deep slow-wave opium-smoking caterpillar who is sitting on a mag- (delta-wave) sleep (Williams & Salamy, 1972). ic mushroom that alters the state of one who eats of Additionally, ethanol reduces the amount of REM it. After returning to the reality of her home in sleep, usually affecting the flint or second REM England, Alice realizes that she had, of course, period. An ethanol concentration in the blood of fallen asleep and been dreaming (Carroll, 1951). 50-milligram percent (mg%) or greater (100-mg% Modern study of the effects of drugs and alcohol is legal intoxication in most states) is necessary for on sleep and dreams dates to the mid-1950s. With observing these sleep effects. The sleep effects of the use of electrophysiological machines, including ethanol are observed only during the first half of an electroencephalograms (EEGs), electrooculo- 8-hour sleep period. Ethanol is metabolized at a grams, and electromyograms, the state of sleep constant rate, and consequently the usual dose of most closely associated with dreaming was discov- ethanol (50-90 mg%) given in these studies is ered, studied, and named REM, for the rapid eye almost completely eliminated from the body after 4 movements unique to that sleep state. In humans, or 5 hours. REM sleep recurs in approximately 90-minute cy- Following elimination of ethanol, an apparent cles throughout the sleep period, resulting in 4 or 5 compensatory effect on sleep occurs. During the REM episodes per night, each lasting from 10 to 30 latter half of sleep, increased amounts of REM sleep minutes. Adults spend about 20 to 25 percent of and increased wakefulness or light sleep is found their sleep period in REM sleep. Abrupt, but not (Williams & Salamy, 1972). Within three to four gradual, awakening from REM sleep is consistently nights of repeated administration of the same dose, associated with the recall of vivid dreaming. While the initial effects on sleep are lost (e.g., tolerance the function of REM sleep is unknown, it appears to occurs), while the secondary disruption of sleep serve a necessary function. Deprivation of REM during the latter half of the night remains. REM sleep by awakenings or by the administration of sleep time and sleep latency return to their basal REM-suppressing drugs leads to a compensatory or levels, and the effects on slow-wave sleep, when rebound effect-specifically, a more rapid onset and initially present, do not persist. When nightly ad- a greater amount and intensity of REM sleep. ministration of ethanol is discontinued, a REM Most psychoactive substances have profound ef- rebound is seen. But the REM rebound after re- fects on sleep and particularly on REM sleep. While peated nightly ethanol administration in healthy, the effects of drugs on REM sleep are known, their nonalcoholic subjects is not a particularly consis- effects on dreaming are being studied. Given the tent result (Vogel et al., 1990). In alcoholics, how- association of REM sleep and dreaming, one might ever, the REM rebound is intense and persistent think that REM-enhancing drugs would increase (Williams & Salamy, 1972). Some believe the pres- dreaming, while REM-suppressing drugs would de- ence of a REM rebound is a characteristic of drugs crease dreaming. But no data suggest such a simple with a high addictive potential. relationship. After the discontinuation of REM- MORPHINE, the opiate ANALGESIC (derived from suppressing drugs, a REM rebound occurs, which is the opium poppy), decreases the number and the reported to be associated with increased and un- duration of REM sleep episodes and delays the pleasant dreams. Some have hypothesized that the onset of the first REM period (Kay et al., 1969). It visual HALLUCINATIONS experienced during dis- also increases awakenings and light sleep and sup- continuation of some drugs (e.g., alcohol) is a REM presses slow-wave sheep. HEROIN, a semisynthetic rebound intruding into wakefulness. It is too sim- opiate, also suppresses REM sleep and slow-wave plistic to think of dreaming and REM in a one-to- sleep and increases wakefulness and light sleep, one correspondence, but it is reasonable to assume producing a disruption of the usual continuity of SLEEP, DREAMING, AND DRUGS 1045 sleep. Heroin appears to be more potent than mor- Nicotine has a paradoxical effect on sleep. In a phine in its sleep effects. The synthetic opiate, study using rats, the higher the dose of nicotine that METHADONE, has similar effects on sleep and wake- was administered, the lower the total sleep time fulness, with a potency more comparable to that of (Salin-Pascual, 1999). In a study that observed the morphine. When an opiate is administered just be- effects of nicotine transdermal patches on depressed fore the onset of sleep, the EEG pattern shows iso- patients, nicotine increased REM sleep time and lated bursts of delta waves on the background of a alleviated some symptoms of depression (Salin- waking pattern. Animal studies have correlated Pascual, 1998). Yet, another study that assessed the these delta bursts with the behavior of head nod- effects of 24-hour transdermal nicotine replace- ding (a possible physiological correlate to the street ment, at four different doses, on sleep showed no term ‘‘being on the nod’’). Repeated administration changes in sleep efficiency from baseline for any of of the opiates at the same dose leads to tolerance of the four doses used (Wolter, 1996). Sleep distur- the sleep effects of these drugs, particularly the bances are possible when a person is attempting to REM sleep effects (Kay et al., 1969). The cessation withdraw from nicotine addiction, along with abil- of opiate use leads to a protracted REM rebound, ity to concentrate. Research has demonstrated that increased REM sleep, and a shortened latency to such withdrawal symptoms are lessened by main- the first REM episode. taining an adequate blood level of nicotine, as can be Among the stimulants, AMPHETAMINE, when ad- supplied by transdermal patches. In that regard, ministered before sleep, delays sleep onset, in- sleep can appear to be enhanced by the administra- creases wakefulness during the sleep period, and tion of 24-hour nicotine patches (Tsoh, 1996). specifically suppresses REM sleep (Rechtschaffen Cocaine also has stimulant effects on the central & Maron, 1964). Cessation of chronic amphet- nervous system, and its effects on electroencephalo- amine use is associated with an increase in slow- gram readings were first studied by Berger in 1931; wave sleep on the first recovery night and, on sub- he was the researcher who developed the EEG (Ber- sequent nights, with increased amounts of REM ger, 1931). Cocaine was found to increase fast- sleep and a reduced latency to the first episode of frequency EEG activity, suggesting an alerting ef- REM sleep, a REM rebound. fect. The self-reported use of cocaine during the Caffeine interferes with sleep in most late afternoon and early evening is associated with nontolerant individuals (Greden, 1997). Once tolerance has developed, people are much less likely to reduced nocturnal sleep time. Systematic electro- report sleep disturbances, or they may sense that physiological studies showa reduction of REM their inability to sleep because of caffeine intake sleep (Watson et al., 1989). Cessation of chronic has completely disappeared. To illustrate, 53 per- cocaine abuse is followed by increased sleep time cent of those consuming less than 250mg per day and a REM rebound. (about 2 to 3 cups of coffee) agreed that caffeine The three classic HALLUCINOGENS are LSD, before bedtime would prevent sleep, compared to MESCALINE, and PSILOCYBIN. The state experienced 43 percent of those consuming 250 to 749 mg per following use of hallucinogens is somewhat similar day, and only 22 percent of those taking 750 mg to dreaming. Since REM sleep is highly correlated per day or more. Even though the higher level caf- with dreaming, scientists expected the hallucino- feine consumers denied that caffeine interferes with gens to facilitate REM sleep, but LSD is the only their sleep, studies done in sleep laboratories con- hallucinogen that has been studied for its effects on firm that caffeine consumers do have greater sleep sleep. One study done in humans showed that LSD latency, more frequent awakenings, and altered enhanced REM sleep early in the night, although it sleep architecture, and that these effects are dose- did not alter the total amount of REM sleep for the related (Greden, 1997). One study that investi- night (Muzio et al., 1966). However, studies done gated the effects of day-long consumption of coffee in animals all indicate that LSD increases wakeful- and tea on sleep onset and sleep quality demon- ness and decreases REM sleep (Kay & Martin, strated that caffeinated beverages had a dose de- 1978). The frequency changes seen in the waking pendent negative effect on sleep onset (PϽ.001), EEG of animals (similar among all three hallucino- sleep time (P[.001) and sleep quality (PϽ.001) gens) suggest an arousing effect. Thus the REM (Hindmarch, 2000). suppression in animals may not be a specific REM 1046 SLEEP, DREAMING, AND DRUGS

effect but rather a sleep-suppressing effect (Fair- BERGER, H. (1931). U¨ ber das Elektroenkephalogramm child et al., 1979). des Menschen. Archiven Psychiat Nervenkrankheiten, Another drug with hallucinogenic effects is mar- 94, 16–60. ijuana, its active ingredient being TETRAHYDRO- CARROLL, L. (1951). Alice in wonderland. NewYork: CANNABINOL (THC). The effects of THC on the Simon and Schuster. waking EEG pattern are quite distinct from the COHEN, D. (1977). Dreams, visions and drugs: A search effects of the classic hallucinogens cited above for other realities. NewYork: NewViewpoints. (Fairchild et al., 1979). THC has sedating effects at FAIRCHILD, M. D., ET AL. (1979). EEG effects of halluci- lower doses and hallucinatory effects at higher nogens and cannabinoids using sleep-waking behav- doses. The acute administration of marijuana or ior as baseline. Pharmacology, Biochemistry & Be- THC to humans is associated with an increase in havior, 12, 99–105. slow-wave sleep and a reduction in REM sleep FEINBERG, I., ET AL. (1976). Effects of high dosage delta- (Pivik et al., 1972). When THC is administered 9-tetrahydrocannabinol on sleep patterns in man. chronically (long-term), the effects on slow-wave Clinical Pharmacology Therapeutics, 17 458–466. and REM sleep diminish, indicating the presence of GREDEN, J. F., WALTERS, A. 1997. Caffeine. In Lowinson tolerance. Discontinuing the use of marijuana is J. H., Ruiz, P., Millman, R.B., Langrod, J. G., eds. associated with increased wakefulness and in- Substance Abuse—A Comprehensive Textbook. Balti- creased REM sleep time (Feinberg et al., 1976). more: Williams & Wilkins. 294–307. Most of these drugs, which are also drugs of HINDMARCH, I., RIGNEY, U., STANLEY, N., QUINLAN, P., abuse, seem to alter sleep and specifically the RYCROFT, J., & LANE, J. 2000. A naturalistic investi- amount and timing of REM sleep. Each affects gation of the effects of day-long consumption of tea, chemicals in the brain that control sleep and wake coffee and water on alertness, sleep onset and sleep and, with chronic use, some adaptation seems to quality. Psychopharmacology (Berl), 149, 203–216. occur. A characteristic REM rebound is seen on KAY, D. C., & MARTIN, W. R. (1978). LSD and trypt- discontinuation of dependent drug use. (It may be amine effects on sleep/wakefulness and elec- that the ancients’ experience of enhanced dreaming trocorticogram patterns in intact cats. Psychophar- was the REM rebound that is typically associated macology, 58 223–228. with protracted drug use.) Some studies indicate KAY, D. C., ET AL. (1969). Morphine effects on human that, in the former drug dependent, the occurrence REM state, waking state, and NREM sleep. Psycho- and intensity of the REM rebound has been predic- pharmacology, 14, 404–416. tive of relapse to drug use. Howthe sleep-wake MUZIO, J. N., ET AL. (1966). Alterations in the nocturnal pattern changes, and specifically the REM changes sleep cycle resulting from LSD. Electroenceph Clin associated with these drugs, contribute to abused Neurophysiol, 21, 313–324. drugs’ excessive use needs further study. PIVIK, R. T., ET AL. (1972). Delta-9-tetrahydrocannabinol and synhexl: Effects on human sleep patterns. ACKNOWLEDGMENTS Clinical Pharmacology Therapeutics, 13, 426–435. Supported by National Institutes of Health RECHTSCHAFFEN, A., & MARON, L. (1964). The effect of (NIAAA) grant no. R01 AA07147 awarded to T. amphetamine on the sleep cycle. Electroenceph Clini- Roehrs and (NHLBI) grant no. P50 HL42215 cal Neurophysiology, 16, 438–445. awarded to T. Roth. SALIN-PASCUAL, R. J., & DRUCKER-COLIN, R. 1998. A novel effect of nicotine on mood and sleep in major depression. Neuroreport, 9, 57-60. (SEE ALSO: Addiction: Concepts and Definitions; Benzodiazepines: Complications; Sedative-Hyp- SALIN-PASCUAL, R. J., MORO-LOPEZ, M. L., GONZALEZ- notics; Sedatives: Adverse Consequences of Chronic SANCHEZ,H.,&BLANCO-CENTURION, C. 1999. Use; Tolerance and Physical Dependence) Changes in sleep after acute and repeated administration of nicotine in the rat. Psychopharmacology (Berl), 145, 133–188. BIBLIOGRAPHY SHEPARD, L. (1984–1985). Encyclopedia of occultism BAUM, L. F. (1956). The Wizard of Oz. NewYork: Gros- and parapsychology, 2nd ed. Detroit: Gayle Re- set and Dunlap. search. SOBRIETY 1047

TSOH, J. Y., ET AL. 1997. Smoking cessation. 2: Compo- SMOKING See Nicotine; Tobacco nents of effective intervention. Behavioral Medicine, 23, 15-27. VOGEL, G. W., ET AL. (1900). Drug effects on REM sleep SMOKING CESSATION See Tobacco; and on endogenous depression. Neuroscience and Treatment: Tobacco Biobehavioral Reviews, 14, 49–63. WATSON, R., ET AL. (1989). Cocaine use and withdrawal: The effect on sleep and mood. Sleep Research, 18, 83. SMOKING CESSATION AND WEIGHT WILLIAMS, H., & SALAMY, A. (1972). Alcohol and sleep. GAIN See Tobacco: Smoking Cessation and In B. Kissin & H. Begleiter (Eds.). The biology of Weight Gain alcoholism, Vol. 2. NewYork: Plenum. WOLTER, T. D., ET AL. 1996. Effects of 24-hour nicotine See Tobacco: Smokeless replacement on sleep and daytime activity during SNUFF smoking cessation. Preventive Medicine, 25, 601–610. TIMOTHY A. ROEHRS SOBRIETY The term sobriety is not defined THOMAS ROTH in current medical or psychiatric literature. The REVISED BY RON GASBARRO term abstinence is found more often and is generally agreed upon as the treatment goal for severe alcoholics. Abstinence is defined as nonuse of the SLEEPING PILLS This is a general term applied to a number of different drugs in pill form substance to which a person was addicted. that help induce sleep, i.e. sedative-hypnotic agents. There is a wide range of such medication SOBRIETY AND SUBSTANCE ABUSE and many require a doctor’s prescription, but some The term ‘‘sobriety’’ is used by members of can be purchased as OVER-THE-COUNTER drugs at ALCOHOLICS ANONYMOUS (AA) and NARCOTICS a pharmacy. These latter preparations generally ANONYMOUS (NA), and also by members of other contain an antihistamine such as chlorpheniramine Twelve-Step groups and recovery groups not affili- maleate, which produces drowsiness. ated with AA. In AA and NA, ‘‘sobriety’’ is often The prescription medications are much stronger. preceded by the adjectives ‘‘stable’’ or ‘‘serene.’’ They include barbiturates, benzodiazepines, and a Abstinence—the condition of being sober—is a number of other compounds. However, due to the necessary but insufficient condition for sobriety. risk for fatal overdose, especially in combination with alcohol or other CNS depressants, the barbitu- Sobriety means something different from the initial rates are no longer widely prescribed for this indi- abstinence so often achieved by alcoholics and cation. In general, the shorter-acting sleeping pills other drug addicts. This initial abstinence is recog- are used to help one relax enough to get to sleep, nized as a time of vulnerability to RELAPSE, often while the longer-acting ones are used to help pre- referred to as a ‘‘dry drunk’’ or ‘‘white knuckle vent frequent awakenings during the night. Long- sobriety.’’ term or inappropriate use can cause TOLERANCE Sobriety in NA and AA. According to AA be- AND PHYSICAL DEPENDENCE. liefs, recovery from ALCOHOLISM and other addictions calls for more than just abstinence. The ad- (SEE ALSO: Sedative-Hypnotic; Sedatives: Adverse dict’s central nervous system must undergo a Consequences of Chronic Use) substantial readaptation. This means that the CRAVING, drug-seeking, dysphoria (unhappiness), BIBLIOGRAPHY and negative cognitions that characterize early abstinence must not only diminish but must also be HOBBS, W. R., RALL, T. W., & VERDOORN, T. A. (1996) replaced by more normal positive behavior. This Hypnotics and sedatives; ethanol. In J. G. Hardman et readaptation requires time and substitute activi- al. (Eds.), The pharmacological basis of therapeutics, ties. The activities most associated with successful 9th ed. (pp. 361–396). NewYork: McGraw-Hill. readaptation are found in TREATMENT programs SCOTT E. LUKAS and in AA or NA. 1048 SOBRIETY

Sobriety, as used by most recovering people in for example, must learn to consume food in mod- AA and NA, refers to abstinence plus a program of eration, not avoid it. Persons addicted to compul- activity designed to make the abstinence comfort- sive spending or shopping cannot simply abstain able and to improve functioning in relationships from making purchases. Members of Sex Addicts and in other aspects of life. The program of recov- Anonymous (SAA) rarely define sexual sobriety as ery that leads to stable sobriety usually includes: ‘‘complete abstinence from sex,’’ although at times (1) attending AA and/or NA meetings; recovering persons may practice complete absti- (2) ‘‘working’’ the Twelve Steps and continuing to nence (celibacy) for a period of time in order to use steps 10, 11, and 12 for the maintenance of gain perspective on their life. In this Twelve-Step sobriety; (3) working with a sponsor who acts as a group, sexual sobriety is most often defined as ‘‘a mentor in maintaining sobriety; (4) belonging to a contract that the sexual addict makes between him/ home group and engaging in service activities that herself and their 12-step recovery support and/or help others with their sobriety; and (5) other activi- their therapist/clergy. These contracts . . . are alties that enhance or support sobriety (e.g., exercise, ways written and involve clearly defined concrete hobbies, and psychotherapy). A program of recov- behaviors from which the sexual addict has com- ery recognizes that any activity has potential to mitted to abstain in order to define their sobriety.’’ either enhance or interfere with the recovering indi- Comparable abstinence contracts are used by re- vidual’s sobriety. In addition, Twelve-Step pro- covering binge eaters, compulsive spenders, rela- grams emphasize the importance of basing sobriety tionship addicts, etc. on positive beliefs and ideals. ‘‘Shotgun sobriety’’ is One benefit of attempts to redefine sobriety in defined in AA as a type of sobriety based only on the context of behavioral addictions is that they fear of drinking. ‘‘Long-term sobriety must be have called attention to the problem of substitute based on spiritual principles, not on fear of alco- addictions, which are addictions that develop when hol.’’ a recovering alcoholic or drug abuser substitutes Sobriety in Non-AA Recovery Groups. food, tobacco, or certain activities (including exer- Secular Organization for Sobriety (SOS), Women cise) for their drug of choice. Many members of for Sobriety (WFS), LifeRing Secular Recovery Twelve-Step groups have found that sobriety re- (LSR), and similar recovery groups for substance quires a re-examination of addictive beliefs and abusers also define sobriety in terms of abstinence attitudes in general as well as abstinence from from drugs and alcohol. A LifeRing pamphlet alcohol or specific drugs. states, ‘‘Please look elsewhere for support if your intention is to keep drinking or using, but not so SPONTANEOUS RECOVERY much, or to stop drinking but continue using, or stop using but continue drinking. The successful One question that has arisen in recent years is LifeRing participant practices the Sobriety Prior- whether some alcoholics can achieve sobriety ity, meaning that nothing is allowed to interfere through spontaneous recovery. G. G. May (1988) with staying abstinent from alcohol and drugs.’’ uses the term ‘‘deliverance’’ for this phenomenon and defines it as ‘‘healing [that] takes the form of empowerment that enables people to modify addic- SOBRIETY AND tive behavior.’’ Some researchers suggest that BEHAVIORAL ADDICTIONS spontaneous remission and recovery is more com- One complication of the term ‘‘sobriety’’ has mon among alcoholics than was once believed, and been the difficulty of defining it in the context of the that it is connected to growth and maturity in the so-called ‘‘process addictions’’ or ‘‘behavioral ad- course of the adult life cycle. G. E. Vaillant (1983) dictions,’’ terms that have been used to distinguish found that most alcoholics in his study outgrew addictions to such activities or behaviors as gam- their drinking problem, more often than not with- bling, shopping, overeating, sexual acting-out, etc. out going into treatment or joining AA. Stanton from substance addictions in the strict sense. Un- Peele (1992) is perhaps the best-known proponent like alcoholics and drug abusers, people with be- of the viewthat ‘‘. . . some people whoappear havioral addictions cannot always define ‘‘sobri- completely out of control of their actions at one ety’’ as simple abstinence. A compulsive overeater, point significantly change their outlooks and ability SOCIAL COSTS OF ALCOHOL AND DRUG ABUSE 1049 to regulate their behavior later in life.’’ He likens SOCIAL COSTS OF ALCOHOL AND spontaneous recovery of sobriety to the ability of DRUG ABUSE Drinking, smoking, and the use some smokers to suddenly quit using tobacco. of psychotropic drugs have a variety of consequences for those who partake of them, for their families and associates, and for society at large. A SUMMARY number of these consequences are negative. Despite these problems of precise definition, the Smokers die young from heart or lung disease, concept of sobriety (abstinence or its equivalent for drinkers get into traffic accidents and fights, drug nonchemical addictions, plus a program of activity injectors spread the HIV virus. In the context of designed to make abstinence comfortable) is a use- public policymaking, where priorities must be set for the use of scarce resources, it seems important ful one for health-care professionals. to have a measure of the overall magnitude of the social burden engendered by such consequences. (SEE ALSO: Addiction: Concepts and Definitions; One familiar approach is to express the magnitude Treatment Types: Minnesota Model; Treatment of the problem in terms of the number of people Types: Self-Help and Anonymous Groups) who die each year. When we learn that there are 107,400 deaths per year in the United States from ALCOHOL abuse (Harwood et al., 1998) and per- BIBLIOGRAPHY haps four times that number from TOBACCO use, we ALCOHOLICS ANONYMOUS WORLD SERVICES. (1976). Alco- knowthat the stakes are very high in devising holics anonymous. NewYork: Author. sound policies for controlling drinking and smok- AMERICAN PSYCHIATRIC ASSOCIATION. (1989). A.P.A. task ing. Such statistics, compelling as they are, tell only force: treatment of psychiatric disorders. Washington, part of the story. In addition to causing early death, DC: Author. substance abuse makes for a variety of consequences that reduce the quality of life, both for AUGUSTINE FELLOWSHIP,SEX AND LOVE ADDICTS ANONY- users and other people. MOUS. (1986). Sex and Love Addicts Anonymous. Bos- To capture this broad array of consequences in a ton: Fellowship-Wide Services, Inc. single number, analysts have estimated various LIFERING SECULAR RECOVERY. (2000). Sobriety is our measures of social cost. The estimates are impor- priority. NewYork: LifeRing Secular Recovery Ser- tant because they figure in the political process by vice Center. which federal funds are allocated to the National LUDWIG, A. M. (1986). Cognitive Processes Associated Institutes of Health and to other agencies that play with ‘‘Spontaneous’’ Recovery from Alcoholism. Jour- a role in combating substance abuse. The most nal of Studies on Alcohol, 47, 53–58. prominent estimates of social costs for substance MAY, G. G. (1988). Addiction & grace: love and spiri- abuse have utilized a conceptual apparatus devel- tuality in the healing of addictions. NewYork: oped by a task force of the U.S. Public Health HarperCollins. Service chaired by Dorothy Rice (Hodgson & Mein- PEELE, S. (1992). Why is everybody always pickin’ on ers, 1979). In 1994, the International Symposium me? A response to comments. Addictive Behaviors, on the Economic and Social Costs of Substance 17, (1) 83–93. Abuse issued guidelines recommending the use of STONE,E.M.(ED.). (1988). American psychiatric glos- this cost-of-illness method in an attempt to estab- sary. Washington, DC: American Psychiatric Press. lish a common foundation and enhance the compa- rability of cost studies conducted in different coun- VAILLANT, G. E. (1983). The Natural history of alcohol- tries (ICAP, 1999). ism. Cambridge, MA: Harvard University Press. Although prominent in policy debate, the cost- WILFORD,B.B.(ED.). (1990). Syllabus for the review of-illness (COI) method has been faulted for its course in addiction medicine. Washington, DC: Amer- emphasis on production as the measure of social ican Society of Addiction Medicine. welfare. Economists favor a quite different ap- JOHN N. CHAPPEL proach that measures social welfare from the per- REVISED BY REBECCA J. FREY spective of the consumer. The economists’ pre- 1050 SOCIAL COSTS OF ALCOHOL AND DRUG ABUSE ferred accounting framework is referred to in this treatment are incorporated in the social-cost esti- article as the ‘‘external social-cost’’ approach. mate. Similarly, the value of law-enforcement and justice resources devoted to alcohol-related crimes THE TWO FRAMEWORKS APPLIED TO are included, as are the costs of replacing property SUBSTANCE ABUSE damaged in traffic crashes and fires caused by drinking. A coherent assessment of the social costs of sub- Several prominent estimates of the total costs of stance abuse requires an accounting framework alcohol abuse for the United States have utilized that specifies criteria for judging which of the myr- the COI framework (Berry & Boland, 1977; iad effects are properly deemed to be of public Harwood et al., 1984 & 1998). In 1998, Harwood concern. For example, in the case of drinking, on et al. published the most complete COI study to any one drinking occasion there may be unwanted, date. Using figures from 1992, the most recent year harmful consequences: social embarrassment, loss for which complete data were available, they found of reputation or affection, failure to discharge some that the economic costs to society of alcohol abuse responsibility at work or home, physical injury totaled $148 billion, broken down as follows: from an accident, victimization by a mugger or About three quarters ($107 billion) of the total rapist, and nausea or hangover. Chronic heavy cost in this tabulation is the value of labor drinking may result in still other consequences, in- PRODUCTIVITY lost as the result of illness, injury, or cluding rejection by family and friends, loss of a job early death. The human capital lost as a result of or of an opportunity for promotion, progressive alcohol-related mortality was computed for all deterioration in physical health, and an early those who died in 1992 from causes in which intox- death. In order to capture these and other negative ication or chronic heavy drinking played a role. consequences in a single number, the list of conse- These include traffic fatalities and deaths from liver quences must be reviewed to determine which cirrhosis, among other causes. The lost human cap- should be considered in establishing priorities for ital was valued by estimating how much the de- substance abuse policy. The consequences deemed ceased would have earned if they had lived and relevant must then be quantified, translated into a worked until retirement age. standard unit of account (dollars), and summed. The human capital lost as a result of morbidity The Cost-of-Illness Framework. The COI was calculated by estimating the reduction in the approach is concerned with measuring the loss or productivity of the labor force resulting from alco- diversion of productive resources resulting from an hol dependence or abuse. Harwood et al. combined illness or activity. In the case of alcohol abuse, two sets of estimates to arrive at this number: first, human capital resources are lost and the gross na- the percentage of the labor force in 1992 that was tional product reduced by the morbidity and early or had ever been subject to a diagnosis of alcohol death suffered by some drinkers, whether as a re- dependence or abuse; and second, an estimate of sult of injuries sustained in alcohol-related traffic the loss in earnings associated with such a diagno- accidents or violent crime or as a result of organ sis. damage and other diseases stemming from chronic Critique. Estimates of this sort have been chal- heavy drinking. The loss to society in these cases is lenged for two reasons. The first challenge is to the equal to the loss of the marginal product of the statistical methods used to generate the estimates of victims’ labor, valued at the market wage. Unpaid morbidity, mortality, and lost earnings (Cook, work at home, including housework and child care, 1991). The second challenge is more fundamental, is included in the computation, with values being for it concerns the basic principles that inform the assigned according to howmuch households pay COI accounting framework. for such services when they are performed by paid The COI procedure estimates the cost of morbid- help. ity and mortality in terms of lost productivity, but The COI approach also takes account of the this emphasis on production as the measure of so- diversion of resources from other productive uses cial welfare seems misplaced. A more liberal per- necessitated by alcohol abuse. Thus the costs of spective, favored by economists among others, medical care for alcohol-related illness, treatment shifts the emphasis to consumption and interprets for ALCOHOLISM, and research on prevention and the task of measuring social welfare in terms of SOCIAL COSTS OF ALCOHOL AND DRUG ABUSE 1051 aggregating individual preferences. Consumers are a number of costs that are ignored in COI become the best judges of their own welfare, and if some- important when the focus is on external costs. times they make choices that fail to maximize their The External Social-Cost Framework. In a productivity, that should not in itself be regarded study at the Rand Corporation, economists applied as problematic. In this view, the choices that people the ESC framework to alcohol abuse and other make concerning how hard to work and when to poor health habits (Manning et al., 1989, 1991). retire are of little public concern. The same goes for Their estimate for alcohol abuse amounted to about choices that place one’s own health and safety at $30 billion in 1985, less than half the COI estimate risk. Thus in economics there is a strong presump- presented above for the same year. The accounting tion in favor of consumer sovereignty, the principle procedures used to generate this estimate of the that the individual consumer is in the best position ESC can be briefly summarized: to define what is best for him or her, and that social welfare is enhanced by free choice within certain 1. Earnings. Heavy drinkers might earn less than limits. A negative consequence is deemed to be of they otherwise would have during their careers public concern only when the actions of one indi- and might have their careers cut short by poor vidual impinge negatively on the welfare of others. health and early death. Although the most obvi- The basic distinction, then, is between internal and ous effect was a reduced standard of living, external consequences of individual decisions, which was properly considered a private cost, a where the latter impose an involuntary cost on number of programs created a collective interest other people. in the productivity of each individual. For ex- In the case of alcohol abuse, the internal costs ample, those who died young saved their fellow include those suffered by drinkers and are foreseea- citizens the expense of years of pension pay- ble as a natural consequence of their choices. A ments and medical costs. Those who retired small example explains the reasoning here. Sup- early (perhaps because of poor health) imposed pose a woman decides to drink heavily tonight financial costs on others in the sense that their despite knowing that she may be tired and unpro- contributions to the Social Security system were ductive tomorrow. By making this decision, she is reduced. Thus these collective financing ar- indicating that for her the pleasure of partying rangements had the effect of creating both ex- outweighs the ‘‘morning-after’’ costs. If no one else ternal costs and benefits in relation to heavy is harmed by this decision, the external costs are drinking. The net effect, according to Manning zero. If she were to drive after drinking, however, et al. (1991), was negative, and equaled about the accounting would change. She would be risking 22 percent of the total external cost. serious injury to herself and to others on the high- 2. Traffic Fatalities. Heien (1996) reported that way. Her injury would have external costs to the about 3,765 of the 13,984 people who died in extent that a third party (group insurance or Med- alcohol-related traffic accidents in 1993 were icaid) paid her medical expenses. The risk that she ‘‘innocent,’’ in the sense that they had not been might injure other people while driving is also a drinking at the time. Their lives had value not negative externality, to be valued at the expected because their work increased the size of the loss to them. That cost, incidentally, is not limited national product, but because they enjoyed life. to their lost earnings, but also includes their pain People are willing to pay to reduce the risk of a and suffering and the suffering of those who care fatal accident, and the social cost of these inno- about them. cent deaths is in principle equal to the total In sum, the most fundamental challenge to the amount the public would be willing to pay to COI framework relates to its presumption that so- eliminate the threat of being killed by a drunk cial welfare is synonymous with national product. driver. Manning et al. (1991) employed this Economists argue instead that the preferences of willingness-to-pay approach and found that individuals are the proper measure of their well- nearly half of the social cost of alcohol abuse being and that social welfare is the sum total of stemmed from traffic fatalities. individual welfare. Some of the major costs in the 3. Other Costs. The remaining $7.2 billion in COI framework, especially lost earnings, are less Manning et al.’s (1991) social cost estimate important in the external social-cost view, whereas stemmed primarily from the burden of alcohol- 1052 SOCIAL COSTS OF ALCOHOL AND DRUG ABUSE

related cases on the criminal justice system, and general approach as their estimate of drinking the share of collision insurance costs accounted costs. They found that over their lifetime smokers for by the property damage caused by drunk experienced higher medical costs than they would drivers. have if they had never smoked, amounting to an average of $0.38 per pack. Since these costs were It appears that in several respects these estimates for the most part paid by insurance, government are incomplete. The costs of alcohol-related injuries programs, or other collective sources, they included to innocent victims are far higher than indicated by them in the external social-cost estimate. Other im- Manning et al., since they omitted the financial and portant external costs were the reduced contribu- personal costs of nonfatal injuries in traffic acci- tions to the Social Security system and related pro- dents (Miller & Blincoe, 1993), and also the costs of grams ($0.65 per pack) resulting from the early both fatal and nonfatal injuries from violent crimes termination of the average smoker’s career, and the perpetrated by drunks. In addition, recent research increased cost to group life insurance programs has suggested that moderate alcohol consumption resulting from the reduced life expectancy of carries measurable health benefits, which must also smokers ($0.11 per pack). Interestingly, these ex- be figured into any equation attempting to assess ternal costs were much less than the external bene- social costs (ICAP, 1999). fits conferred by smoking. Because smokers died An even more interesting controversy has arisen young, the pension payments were much less than over the basic perspective that informs these exter- they would have been otherwise ($1.82 per pack), nal social-cost estimates. Some critics reject out- and the likelihood that they would be housed in a right the liberal doctrine that individual prefer- collectively financed nursing home was also sub- ences are to be accorded primacy in the definition stantially reduced ($0.26 per pack). The result was of social welfare and social cost. They postulate a that each pack of cigarettes smoked conferred a net collective interest that can somehowbe defined social benefit amounting to $0.91. without reference to the choices made by individu- The calculations used to arrive at these figures als (Beauchamp, 1980). The COI approach reflects are quite complex. Cigarettes smoked in different one such definition. Other critics accept the liberal years may have variant health effects. Tar content doctrine but argue about its application. A particu- in cigarettes, for example, has decreased three to larly difficult set of philosophical and practical is- four percent since World War II. It is generally sues arise in setting the boundary between internal believed that cigarettes containing lower amounts and external costs in the context of the family. of tar cause fewer health problems. Since over the Manning et al. (1991) viewthe family as a unit and course of a smoking career the social costs generally accept the presumption that each member of the precede the benefits, the net benefit to society was family will internalize the concerns of the others reduced if future costs and benefits were discounted and act accordingly. Harwood et al. found that, in (standard practice in accounting). The appropriate 1992, abusers and their households bore $66.8 bil- discount rate to be applied to these calculations is a lion of the total cost of alcohol abuse. If the father is matter of some dispute. It turned out that with a a heavy drinker or smoker, it is not because he is discount rate of five percent, the lifetime present unaware or unconcerned about the consequences value of the external effects of smoking amounted for his wife and children of his drinking or smok- to a net external cost of $0.15. Manning et al. point ing, but because his enjoyment of these activities in out that smokers more than pay this cost in the some sense outweighs the costs to them. That pre- form of the state and federal excise taxes imposed sumption may seem particularly problematic in the on tobacco. The external effects in this calculation case where the mother’s substance abuse causes her are all financial; they stem from private and gov- baby to be born defective. ernment programs that have the effect of forcing us to pay for each other’s medical care, retirement, and other benefits. Smoking, however, also causes COSTS OF SMOKING AND external effects directly, since smoke pollutes the DRUG ABUSE air we all breathe. The value of clean air for non- Manning et al. (1989) provided an estimate of smokers could in principle be estimated and added the social costs of smoking that utilized the same to the total external cost. Manning et al. chose not SOCIAL COSTS OF ALCOHOL AND DRUG ABUSE 1053

to do so, in part because they believe that the bulk (SEE ALSO: Accidents and Injuries; Complications; of the costs of secondhand smoke is borne by those Economic Costs of Alcohol Abuse and Alcohol De- in the same household as smokers. However, in pendence; Productivity: Effects of Drugs and Alco- 1995, taking into account the consequences of sec- hol on) ond-hand smoke, Viscusi brought the estimate of the net social benefit of smoking down to a more BIBLIOGRAPHY modest, but still beneficial, $0.07 per pack, assessing the costs of second-hand smoke at $0.25 per BEAUCHAMP, D. E. (1980). Beyond alcoholism: alcohol pack. and public health policy. Philadelphia: Temple Uni- Applying the external social-cost framework to versity Press. smoking and other harmfully addictive activities BERRY, R. E., & BOLAND, J. P. (1977). The economic cost raises another issue. The vast majority of smokers of alcohol abuse. NewYork: Free Press. begin their habit as adolescents, so the obvious COOK, P. J. (1991). The social costs of drinking. In Ex- question is whether people at that age are making pert meeting on the negative social consequences of well-informed decisions that take proper account of alcohol abuse. Oslo: Norwegian Ministry of Health the lifetime consequences (Goodin, 1989). Adoles- and Social Affairs. cents tend to be as well informed about the health GOODIN, R. E. (1989). No smoking: The ethical issues. risks of smoking as adults, and both groups, if Chicago: The University of Chicago Press. anything, exaggerate these risks (Viscusi, 1992). Harwood, H. J., ET AL. (1998). The economic costs of However well informed they are, most people who alcohol and drug abuse in the United States: 1992. acquire a smoking habit nevertheless end up wish- Rockville, MD: The National Institute on Drug Abuse ing they could quit. and the National Institute on Alcohol Abuse and Alco- In considering the social costs of illicit drug use, holism. the illegal status of these drugs makes an enormous HEIEN, D. M. (1996). Are higher alcohol taxes justified? difference (Kleiman, 1992). The consequences of The Cato Journal, 15(2–3). criminalizing transactions in these drugs include HODGSON, T., & MEINERS, M. (1979). Guidelines for cost- the bloody wars between rival drug-dealing organi- of-illness studies in the public health service (Task zations, crime by addicts seeking funds for their Force on Cost-of-Illness Studies). Bethesda, MD: Pub- next fix, and the spread of disease through use of lic Health Service. unclean needles, as well as the billions of dollars INTERNATIONAL CENTER FOR ALCOHOL POLICIES. (1999). spent in law-enforcement efforts. Harwood et al. Estimating costs associated with alcohol abuse: estimated that, in 1992, drug abuse problems in- Towards a patterns approach. ICAP Reports, 7. curred a social cost of $97.7 billion. KLEIMAN, M. A. R. (1992). Against excess: drug policy for results. NewYork: Basic Books. MANNING, W. G., ET AL. (1991). The costs of poor health CONCLUSION habits. Cambridge, MA: Harvard University Press. In conclusion, the effort to produce estimates of MANNING, W. G., ET AL. (1989). The taxes of sin: Do the social costs of drinking, smoking, and drug smokers and drinkers pay their way? Journal of the abuse is motivated by an interest in establishing a American Medical Association, 261, 1604–1609. scientific basis for setting priorities in government MILLER, T. R., & BLINCOE, L. J. (1993). Incidence and programs. This effort has produced some useful cost of alcohol-involved crashes. Unpublished manu- results and a good deal of controversy surrounding script. the issue of what is to be counted and how. The task RICE, D. P., ET AL. (1990). The economic costs of alcohol of estimating the social costs of substance abuse and drug abuse and mental illness: 1985 (Report sub- requires an accounting framework, and the choice mitted to the Office of Financing and Coverage Policy of a framework is not a technical, scientific issue of the Alcohol, Drug Abuse, and Mental Health Ad- but rather a matter of political philosophy. This is ministration, U.S. Department of Health and Human surely one area where the numbers do not speak for Services). San Francisco: University of California, In- themselves. stitute for Health and Aging. 1054 SOCIAL MODEL

RICE, D. P. (1999). Economic costs of substance abuse, 1995. Proceedings of the Association of American Physicians. VISCUSI, W. K. (1995). Cigarette taxation and the social consequences of smoking. Tax Policy and the Econ- omy, 9. Cambridge, MA: National Bureau of Eco- nomic Research. VISCUSI, W. K. (1992). Smoking: Making the risky decision. NewYork: Oxford University Press. PHILIP J. COOK REVISED BY SARAH KNOX

SOCIAL MODEL See Disease Concept of Alcoholism and Drug Abuse

SOCIETY OF AMERICANS FOR RECOV- ERY (SOAR) See Treatment Programs/Centers/ Organizations: An Historical Perspective

SOLVENTS See Inhalants Over 60 percent of the heroin that is sold in the United States originates in the poppy fields of SOURCE COUNTRIES FOR ILLICIT Southeast Asia, particularly Myanmar, Thailand, and Laos. (Drug Enforcement Administration) DRUGS The 1987 Omnibus Drug Bill requires the U.S. Department of State to develop a list of all major illicit drug-producing and drug-transit and Peru substantially reduced those countries’ countries. Inclusion on the list has an immediate cultivation of coca plants. Despite these efforts, effect, because sanctions include cutting off foreign drug traffickers shifted their production to Colom- assistance, other than humanitarian and coun- bia, which by 2000 had become the dominant pro- ternarcotics aid. In addition, the U.S. will block ducer of cocaine. Major source countries for mari- loans by the World Bank to countries that are juana are MEXICO, Belize, COLOMBIA, and Jamaica. included on the list. However, the U.S. Drug Enforcement Administra- Major illicit drug producing country is defined in tion estimates that much of the marijuana con- the statute as any country producing ‘‘during a sumed in the United States is grown domestically, fiscal year five (5) metric tons or more of OPIUM or qualifying the U.S. as a source country. Major opium derivative, 500 metric tons or more of coca, source countries for HASHISH are Lebanon, Paki- and 500 metric tons or more of MARIJUANA.’’ (One stan, Afghanistan, and Morocco. metric ton equals 1.102 tons.) Measured in U.S. dollar value, at least 80 per- The major source countries for HEROIN are Af- cent of all illegal drugs consumed in the United ghanistan, Pakistan, Iran, and Lebanon; Myanmar States are of foreign origin, including all the co- (formerly Burma), Thailand, and Laos; Mexico, caine and heroin and significant amounts of mari- Guatemala, and Colombia. Heroin production rose juana. The opium poppy flower, coca bush, and dramatically in South America in the 1990s. Co- marijuana plant represent cash crops for indige- lombian and Mexican heroin have supplanted nous populations—who use the proceeds of sale for Southeast and Southwest Asian heroin in much of subsistence, improvements in lifestyle, and/or the United States. Major source countries for CO- means to procure weapons to engage in an- CAINE are BOLIVIA, Colombia, Peru, and Ecuador. tigovernment activities. The cultivation of illicit However, in the 1990s, the governments of Bolivia drug crops often represents the most viable—at STILL 1055

times the only viable—economic alternative avail- control strategy report (INCSR). Washington, DC: able to otherwise impoverished farmers and politi- Author. cal refugees. Foreign Assistance Act, as amended 1961, ch. 8, sec 481 (h). Washington, DC: U.S. Congress. CERTIFICATION PERL, R. F. (1989). Congress and international narcotics control. CRS Report for Congress (October 16). Wash- Chapter 8, Section 481 (h) of the Foreign Assis- ington, DC: Library of Congress. tance Act, known as the Certification Law, links the WHITE HOUSE OFFICE OF NATIONAL DRUG CONTROL POL- provision of foreign aid to positive drug-control ICY. (2000). National Drug Control Strategy: 2000 performance. The lawalso requires the president to Annual Report. Washington, DC: U.S. Government certify whether major drug-producing and drug- Printing Office. transit countries have ‘‘cooperated fully’’ with the JAMES VAN WERT United States, or have taken adequate steps on REVISED BY FREDERICK K. GRITTNER their own, to prevent illicit drug production, drug trafficking, drug-related MONEY LAUNDERING, and drug-related corruption. A later amendment to the act requires countries to take adequate steps to SOUTHEAST ASIA, DRUGS AND See Asia, Drug Use in; Golden Triangle; Source Coun- implement the 1988 United Nations Drug Conven- tries for Illicit Drugs tion. Four outcomes of the certification statute de- liberation are possible: (1) full and unconditional certification; (2) qualified certification for countries that would not otherwise qualify on the SPECIAL ACTION OFFICE FOR DRUG grounds that the national interest of the United ABUSE PREVENTION (SAODAP) See U.S. States requires the provision of foreign assistance; Government Agencies (3) denial of certification; or (4) congressional disapproval of a presidential certification, which causes statutory sanctions to be imposed. SPORTS AND DRUG USE See Anabolic The annual International Narcotics Control Steroids Strategy Report (INCSR) is prepared by the U.S. Department of State and provides the factual basis for the president’s decision on certification. The STATE DRUG PROGRAMS See certification statute introduces the concept of vari- Appendix, Volume 4 ability, by using phrases such as ‘‘cooperated fully,’’ ‘‘taken adequate steps,’’ and ‘‘maximum achievable reductions.’’ Judgments on a country’s STEROIDS See Anabolic Steroids relative capability to perform are important factors in making certification decisions; each March, these generate spirited debate between the legislative and executive branches of the U.S. government. In ad- STILL Still is the colloquial term for distill- dition, this very public decision-making produces ery, a device used for DISTILLATION—to extract tensions between the U.S. and the countries in ethyl alcohol (ethanol) from various plants and question. food products. The simplest ones contain a cooking pot and a tightly fitted cap from which a long arm extends in a downward direction. A mash is boiled, (SEE ALSO: Drug Interdiction; International Drug the ethyl alcohol rises to the top and is deposited as Supply Systems; Transit Countries for Illicit Drugs) a vapor which then condenses as it cools and passes through the arm. BIBLIOGRAPHY

BUREAU OF INTERNATIONAL NARCOTICS AND LAW, U.S. DE- (SEE ALSO: Alcohol: History of Drinking) PARTMENT OF STATE. (1999). International narcotics SCOTT E. LUKAS 1056 STIMULANTS

STIMULANTS See Drug Types (SEE ALSO: Drug Interdiction; Drug Laws: Prosecu- tion of; Seizures of Drugs) PETER REUTER STP See DOM REVISED BY MARY CARVLIN

STRESS Stress is best thought of as a nega- STRAIGHT, INC. See Appendix, Volume 4 tive emotional state—a psychophysiological experience that is both a product of the appraisal of situational and psychological factors as well as an STREET DRUGS See Slang and Jargon impetus for coping (Baum, 1990). Stressors— events posing threat or challenge or otherwise demanding effort and attention for adaptation—are judged in terms of the situational variables and STREET VALUE When drugs are seized by one’s personal attributes and assets. Negative affect a police or interdiction agency, the significance of may ensue; and stress responses, which appear di- the seizure is often measured in terms of its street rected at the mobilization of bodily systems as a value, that is, the revenues that would be fetched if means of coping, strengthen specific problem each gram were sold at the current retail price. solving aimed at eliminating the sources of threat Such measures are routine among police and cus- or demand and at reducing emotional distress toms service agents in the United States and in most (Baum, Cohen, & Hall 1993). other nations, although large price fluctuations can occur from one area to another and within short (SEE ALSO: Vulnerability As Cause of Substance time frames. Abuse) The use of the term street value is potentially misleading when it is intended to convey the signif- BIBLIOGRAPHY icance of the seizure as a loss to the traffickers. The price of drugs rises steeply as they move down the BAUM, A. (1990). Stress, intrusive imagery, and chronic distribution chain from point of importation. In the stress. Health Psychology, 1, 217–236. BAUM, A., COHEN, L., & HALL, M. (1993). Control and 1990s, for example, a gram of cocaine could sell on intrusive memories as determinants of chronic stress. the streets of a U.S. city for about $75. That gram Psychosomatic Medicine, 55, 274–286. (1,000 milligrams) contained approximately 700 milligrams (mg) of pure cocaine—so that the ‘‘pure LORENZO COHEN gram’’ price was about $106. Yet when sold in 100- ANDREW BAUM kilogram (kg) units at the point of import, the cocaine could have sold for a pure-gram price of about $20. Thus it would cost drug traders $2 STRUCTURED CLINICAL INTERVIEW million to replace the 100 kilograms. That figure is FOR DSM-IV (SCID) This is a diagnostic in- the total value of payments that would have to be terviewdesigned for use by mental health professionals. It assesses thirty-three of the more com- made to growers, refiners, and smugglers in order monly occurring psychiatric disorders described in to obtain another 100 kilograms and bring the drug the fourth edition of the DIAGNOSTIC AND STATISTI- to the same point in the distribution system. CAL MANUAL (DSM-IV) of the American Psychiatric Valuing a 100-kg seizure at street value would Association (1994). Among these are MOOD DISOR- then imply that the government had inflicted a DERS (including MAJOR DEPRESSIVE DISORDER), PSY- $10.6 million blowto the drug industry, more than CHOTIC DISORDERS (including SCHIZOPHRENIA), five times as much as the true value of the loss. The ANXIETY DISORDERS (including PANIC DISORDER) extent of overstatement increases with the size of and the substance-use disorders. The SCID is a the seizure, since the price of drugs goes down as semi-structured interviewthat allowsthe experi- the volume increases in a given transaction. enced clinician to tailor questions to fit the patient’s STRUCTURED CLINICAL INTERVIEW FOR DSM-IV (SCID) 1057 understanding; to ask additional questions that have been present during the last month; and age clarify ambiguities; to challenge inconsistencies; when the first symptoms appeared. If dependence is and to make clinical judgments about the serious- current, the interviewer rates the current severity as ness of symptoms. The main uses of the SCID are mild, moderate, or severe. If dependence is in par- for diagnostic evaluation, research, and the train- tial or full remission, the appropriate DSM-IV re- ing of mental-health professionals. mission specifier is noted (e.g., early partial remis- The SCID is modeled on the standard clinical sion, sustained full remission, etc.). Because alcohol interviewpracticed by many mental-health profes- use is so much more common the other substance sionals. It begins with an overview section that use, the assessment for alcohol dependence and includes questions about basic demographic infor- abuse is conducted first, followed by an assessment mation (e.g., age, marital status), educational his- of dependence or abuse on the remaining categories tory, and work history, followed by questions about of substances. the chief complaint, past episodes of psychiatric The ALCOHOL (ethanol) section of the SCID disturbance, treatment history, and current func- begins with some overview questions about the tioning. The remainder of the interviewis orga- subject’s drinking history (e.g., ‘‘has there ever nized into the following sections: mood episodes, been a period when you had five or more drinks on psychotic symptoms, differential diagnosis of psy- one occasion?’’ ‘‘has anyone ever objected to your chotic disorders, differential diagnosis of mood dis- drinking?’’). The subject’s answers to these initial orders, substance-use disorders, anxiety disorders, questions allowthe interviewerto sequence the as- somatoform disorders, eating disorders, and ad- sessment questions to match the subject’s drinking justment disorder. A separate interview, the Struc- history as follows: If a history of dependence seems tured Clinical Interviewfor DSM-IV Axis II Person- likely (e.g., the subject reports a history of detoxifi- ality Disorders (SCID-II) is available for the cation from alcohol or attendence at AA), the inter- assessment of personality disorders. viewer begins with the assessment of the individual The SCID comes in two basic versions: the re- DSM-IV dependence criteria. (If criteria are met for search version (known as the SCID-I) and the clini- dependence, the assessment of abuse is skipped cian version (SCID-CV). The research version con- since a DSM-IV diagnosis of dependence pre-empts tains the full complement of disorders, subtypes a diagnosis of abuse; if criteria are not met for and specifiers that are of interest to researchers. It is dependence, then the interviewer continues with provided by the Biometrics Research Department the assessment of abuse). If the history is not sug- at Columbia University as an unbound packet of gestive of dependence but is indicative of excessive pages so that the investigator has the ability to drinking or problematic use, the interviewer com- leave out pages covering disorders or subtypes that mences with the individual DSM-IV criteria for are not relevant to a particular study. The bound abuse. (If the criteria are met for abuse, the inter- clinician version (published by American Psychiat- viewer must then continue the assessment to see if ric Press) includes only those disorders and speci- the problematic drinking is sufficiently severe to fiers that are the most clinically relevant. Training qualify for dependence). Only if there have never materials and computerized versions are also avail- been any episodes of excessive drinking and there is able. Additional detailed information about the no evidence of alcohol-related problems can the SCID (including differences between the research interviewer skip the alcohol section and move on to and clinician versions, ordering information, train- the assessment of other substances. ing materials, references) is available on the SCID The drug section of the SCID is similarly struc- web site (www.scid4.org). tured to tailor the sequence of questions to the The substance use disorders covered in the SCID subject’s drug-taking history. If, for any class of are dependence and abuse for seven classes of sub- substance, the subject reports having used the substances: alcohol, sedative-hypnotics-anxiolytics, stance on at least 10 occasions in any one month Cannabis (marijuana), Stimulants, Opioids, Co- period, the interviewer starts with the assessment caine, and Hallucinogens/PCP. For each sub- for dependence. If the subject reports using a substance, the interviewer determines whether the stance at least twice, but less than 10 times in any symptoms of dependence or abuse have ever been month, the assessment focuses on abuse. (As with present during the subject’s lifetime; whether they the assessment for alcohol, if criteria are met for 1058 STUDENTS AGAINST DESTRUCTIVE DECISIONS (SADD) abuse, the interviewer follows up with the assess- Students who took Anastas’s course reacted en- ment for dependence). For prescribed medications, thusiastically and formed an organization to reduce the interviewer checks for dependence if the subject alcohol-related traffic deaths among their peers. reports taking having been ‘‘hooked’’ on the medi- They initially called the organization Students cation or reports often taking more of it than pre- Against Driving Drunk (SADD) in order to focus scribed. attention on the act of drunk driving, not on the drivers themselves. An anecdote related by Peggy (SEE ALSO: Addiction: Concepts and Definitions; Mann (1983) captures SADD’s approach and phi- Complications: Mental Disorders; Disease Concept losophy: When a student jokingly suggested that of Alcoholism and Drug Abuse; Epidemiology of SADD involve the governor, Anastas replied, ‘‘I be- Drug Abuse; International Classification of Dis- lieve that if you dream it, it can be done,’’ and when eases) the governor became the honorary chairman of SADD, its motto became ‘‘If You Dream It, It Can BIBLIOGRAPHY Be Done.’’ Within a year, chapters had been formed throughout Massachusetts and the program was AMERICAN PSYCHIATRIC ASSOCIATION. (1994). Diagnostic gaining national attention. and statistical manual of mental disorders-4th edi- Members of the early SADD chapters had a tion. Washington, DC: Author. number of goals. They sought to raise awareness of FENNIG S, NAISBERG-FENNIG S, CRAIG TJ, ET AL. (1996). impaired driving among students through the cur- Comparison of clinical and research diagnoses of sub- riculum developed by Anastas. They also sought to stance use disorders in a first-admission psychotic change norms related to impaired driving. Because sample. Am J Addiction 5 40-48. they realized that most of their peers did not think FIRST MB, ET AL. (1997). Structured clinical interviewfor of drinking and driving as wrong or risky, they DSM-IV—clinical version (SCID-CV) (User’s Guide reasoned that changing these norms was an impor- and Interview). Washington, D.C.: American Psychi- tant component of reducing impaired driving prob- atric Press, Inc. lems. As the students put it, they wanted to change KRANZLER HR, KADDEN RM, BABOR TF, ET AL. (1996) the ‘‘drinking and driving is cool’’ image to another Validity of the SCID in substance abuse patients. Ad- image: ‘‘Drinking and driving is dumb.’’ Finally, diction 91, 859-868. students in the SADD chapters undertook to simu- SPITZER, R. L., ET AL. (1992). The structured clinical late discussion between high school students and interviewfor DSM-III-R (SCID). I. History, rationale their parents concerning drinking and driving. To and description. Archives of General Psychiatry, 49, meet this goal, they developed a ‘‘Contract for 624-629. Life.’’ The contract stipulated that a student would THOMAS F. BABOR call a parent if he or she had been drinking or if the REVISED BY MICHAEL B. FIRST person responsible for driving had been drinking, and the parent, in turn, agreed to provide a ride or taxi fare. STUDENTS AGAINST DESTRUCTIVE SADD was significant in three important ways. DECISIONS (SADD) In 1981, Robert Anastas, First, it was among the earliest prevention pro- a health educator and hockey coach in Wayland, grams to emphasize student leadership. Other pro- Massachusetts, stood helplessly by as two of his grams had used peer educators or peer counselors students died of injuries sustained in two separate trained and supervised by adults, but SADD chap- alcohol-related traffic crashes. Anastas decided to ters were run by students who planned activities fight back and developed a fifteen-session high and took responsibility for making them happen. school course on driving while impaired. Rather Second, SADD was among the first youth programs than a curriculum focusing solely on the effects of to recognize the importance of norms in impaired- alcohol while driving, he taught strategies for pre- driving prevention. Earlier programs had empha- venting driving after drinking, and he emphasized sized education, attitude change, or scare tactics. the legal consequences of getting caught. In this Third, SADD was one of the first school-based pre- sense, the curriculum was a significant departure vention programs to venture outside the classroom. from traditional driver-education approaches. Although SADD had a curriculum, it also entailed SUBSTANCE ABUSE AND AIDS 1059 extracurricular, community, and family involve- port activities on a range of issues around risky ment. In this sense, SADD was the first of the behaviors. In recent years, several student safety so-called comprehensive school-based prevention clubs with very similar approaches to that of SADD programs. have emerged. Members of these clubs, like SADD SADD’s early growth was rapid. By the mid members, encourage students reaching out to other 1980s, there were SADD chapters in every state in students to reduce highway deaths. the United States and chapters in Europe. SADD As is the case with many widespread, visible received considerable media attention and was the prevention efforts, little measurable data can be only alcohol-prevention program ever to be the summoned to showwhetheror not SADD is effec- subject of a nationally broadcast made-for-televi- tive in reducing drinking and driving among youth. sion movie (‘‘Contract for Life: The Bob Anastas In 1995, the Preusser Research Group, with fund- Story’’). ing from the National Highway Traffic Safety Ad- SADD was also controversial. Some vocal critics ministration, performed an evaluation of SADD’s argued that SADD’s emphasis on preventing drink- effectiveness and concluded that students attending and driving implicitly condoned drinking by ing a SADD school were exposed to substantially young people. They were particularly concerned more activities and information about the risks of about the Contract for Life— they argued that by underage drinking and drinking and driving. The insuring safe transportation, parents were commu- survey also found that students at SADD schools nicating the message that drinking itself was not a were more likely to hold positive attitudes against problem. Similar charges were leveled at Safe Rides drinking and driving. and other programs that provided sober transportation for youth. Anastas and others countered that (SEE ALSO: Accidents and Injuries from Alcohol; although drinking itself was a problem, young peo- Dramshop Liability Laws; Drunk Driving; Mothers ple were dying from traffic crashes, not just from Against Drunk Driving; Prevention Movement) drinking. This debate, which resulted in the refusal by BIBLIOGRAPHY some funding agencies to allowgrant money to be used to support SADD chapters, raged throughout KLITZNER, M., ET AL. (1994). A quasi-experimental eval- the 1980s. SADD was also subject to criticism be- uation of Students Against Driving Drunk. American cause of its acceptance of funding from the alco- Journal of Alcohol and Drug Abuse, 20, 57–74. holic beverage industry. In 1989, SADD divorced MANN, P. (1993). Arrive alive: How to keep drunk and itself from this source of funds. It also adopted a pot-high drivers off the highway.NewYork: strong ‘‘No Use’’ message and amended its Con- Woodmere Press. tract for Life to emphasize its commitment to a MICHAEL KLITZNER drug- and alcohol-free lifestyle. The organization REVISED BY PATRICIA OHLENROTH specifically disassociates itself from ‘‘safe rides’’ and ‘‘designated driver’’ programs. However, it continues to characterize itself as an ‘‘inclusive, not SUBSTANCE ABUSE See Addiction: Con- exclusive’’ organization, recognizing that teenagers cepts and Definition make mistakes and should not be punished for them. Over the years, SADD has evolved. Junior high SUBSTANCE ABUSE AND AIDS AIDS school and college programs have been added, as stands for acquired immunodeficiency syndrome: has an emphasis on seat-belt use. In 1997, in re- AIDS is a life-threatening disease that results from sponse to calls from its chapters, the organization severe damage to part of the body’s cellular im- amended its popular name to Students Against mune system—the defense system against oppor- Destructive Decisions, incorporating in its mandate tunistic infections and some cancers. The disease is other potentially destructive behaviors such as acquired (as opposed to genetic or hereditary) and underage drinking and drug use, teen suicide, vio- presents a myriad of clinical manifestations (syn- lence, and HIV/AIDS. Today, SADD chapters focus dromes) that result from severe damage to the im- primarily on education, awareness and peer sup- mune system. AIDS was first identified in 1981 1060 SUBSTANCE ABUSE AND AIDS among homosexual men in California and New ratories in large amounts, which led to the develop- York, and among illicit injected-drug abusers in ment of laboratory tests that detect HIV infection. NewYork City. After 1981, the numbers and types HIV gradually destroys certain white blood cells cells. The םof AIDS patients increased rapidly; it was diag- called T-helper lymphocytes or CD4 nosed in millions of persons throughout the world. loss of these cells results in the body’s inability to In the United States alone, the Centers for Disease control microbial organisms that the normal im- Control (CDC) estimated in 1996 that 1 million mune system controls easily. These infections are persons were HIV-positive and 223,000 were living called opportunistic because they take advantage of with AIDS. damage to part of the immune system. A fewselect By 1996, injecting drug abusers accounted for cancers are also frequently diagnosed, such as 26 percent of cases among men, 70 percent of cases Kaposi’s sarcoma, a cancer of blood vessels, which among women, and about 55 percent of pediatric appears as purplish spots on the skin or mucous cases—the children of mothers who are either in- membranes. jecting drug abusers or the sexual partners of male The sharing of needles contaminated with HIV injecting drug abusers. As of 1997, it was estimated for injecting drugs of abuse may lead to infection that 84 percent of HIV-positive women were of with HIV—but drug abuse may also act as a childbearing age; 41 percent of them were drug cofactor with HIV, affecting the development of abusers. AIDS is one of the 10 leading causes of AIDS. A co-factor in AIDS is a non-HIV-related death in children between one and four years of influence operating in conjunction with HIV to af- age. Women with AIDS do not live as long as men, fect the cause of the disease. For example, HIV- though the reasons for this finding are still unclear. infected individuals who continue to inject drugs The finding has been attributed to the hormonal and/or continue tobacco use may not survive as changes of pregnancy, to poverty, and to violence long as those who do not abuse those substances. against women. AIDS has been diagnosed among The abuse of nitrite INHALANTS (‘‘poppers’’) among injectors of various illicit substances, including HIV-infected homosexual men may promote the development of Kaposi’s sarcoma. OPIATES,COCAINE,AMPHETAMINES, and ANABOLIC STEROIDS. AIDS has also been reported among non- injecting drug abusers, such as alcoholics, cocaine SIGNS AND SYMPTOMS ‘‘snorters,’’ and crack (cocaine) smokers, who have Early HIV Infection. The natural history of been infected through sexual contact. An epidemic HIV disease and the time intervals between clinical like AIDS that spans the continents is appropriately events vary greatly from individual to individual. called a pandemic. The general course, however, is one of exposure to HIV, which leads to infection. Within a few weeks CAUSE or months of infection, laboratory evidence of infection can be detected as the presence of virus in AIDS is caused by a viral infection. In the United the blood (viremia) or the appearance of the p24 States, the virus is called HIV (for human immuno- antigen. Antibodies to HIV are found in the blood deficiency virus); it is one of a group of viruses and indicate that infection has occurred. Some pa- called retroviruses (so-called because they can tients develop flulike symptoms resembling mono- make DNA copies of their RNA—the reverse of nucleosis or peripheral nerve abnormalities that are what typically occurs in animal cells). In 1983, self-limited. This first stage of HIV infection is French researchers discovered the virus, which they called the acute retroviral syndrome. Most patients had linked to an outbreak of enlarged lymph nodes have no symptoms during this period. (one early sign of HIV infection) that had been Latency Period. Over the ensuing years of a reported among French male homosexuals. The second, or latency, period (1&endash;15 or more French named it the lymphadenopathy-associated years), laboratory evidence of a decreasing number virus (LAV). In 1984, U.S. researchers isolated of helper T-lymphocytes can be measured. As the HIV from AIDS patients and named it human helper T-lymphocyte count decreases, patients are T-lymphotropic virus type III (HTLV-III). Ameri- more likely to develop such signs and symptoms as can investigators found a way to grow HIV in labo- enlarged lymph glands, fatigue, unexplained fever, SUBSTANCE ABUSE AND AIDS 1061 weight loss, diarrhea, and night sweats. At about Nucleoside Analogues. These drugs work by the same time or later, patients develop opportunis- interfering with the replication process of the HIV tic infections or cancers. The diagnosis of one of the virus. They include zidovudine (ZDV, AZT), opportunistic infections or cancers indicates that didanosine (ddI), zalcitabine (ddC), stavudine the patient has developed AIDS. Pneumocystis (d4T), and lamivudine (3TC). carinii pneumonia, a fungal infection of the lung, is Nonnucleoside Reverse Transcriptase In- the most common opportunistic infection among hibitors. These drugs work by blocking the activ- AIDS patients. Other opportunistic infections in- ities of the RNA and DNA in infected cells. They clude candidiasis of the mouth (thrush), include nevirapine and delavirdine. The drawback cryptococcal meningitis, amebiasis, and of this group of drugs is that the virus quickly cryptosporidiosis. Tuberculosis is another serious develops resistance to them. infection that has become increasingly common be- Protease Inhibitors. These are considered the cause of the AIDS pandemic. most potent antiviral drugs. They inhibit the viral Late-Stage AIDS. Late-stage AIDS is usually proteinase enzyme, which results in noninfectious marked by a sharp decline in the number of lym- particles of virus. The protease inhibitors include phocytes, followed by a rise in the number of op- saquinavir, ritonavir, indinavir, and nelfinavir. portunistic infections and cancers. Kaposi’s sar- As of 1999 through 2000, these drugs were coma is the most common cancer among AIDS usually given in combinations of at least two and patients. Kaposi’s sarcoma usually arises in the preferably three compounds. Triple combinations skin and looks like a bruise or an area of bruises, including one of the protease inhibitors are consid- but it grows and spreads to the internal organs. ered the most powerful antiviral regimens. All anti- Another common type of cancer in late-stage AIDS viral treatment regimens must be individualized to is a form of lymphoma, or a tumor of the lymphatic the patient. system. Patients with late-stage AIDS may also develop inflammations of the muscles, arthritis-like HIV TRANSMISSION pain in the joints, and AIDS dementia complex. AIDS dementia complex is marked by loss of rea- HIV can be transmitted from person to person in soning ability, apathy and loss of initiative, loss of three ways: (1) by contact with infected blood or memory, and unsteadiness or weakness in walking. blood components; (2) through intimate sexual contact; and (3) from an infected pregnant mother to her fetus. Drug abusers commonly become in- DIAGNOSIS AND TREATMENT fected by sharing needles, syringes, and other in- Infection with HIV can be diagnosed with a jecting paraphernalia; injecting substances—such blood test measuring antibodies to the virus. Anti- as heroin, cocaine, and amphetamines—after an bodies are proteins produced by certain white HIV-infected person uses the needle and syringe blood cells in response to injection. The HIV anti- causes direct inoculation of HIV. Using any para- body test became widely available in 1985. As of phernalia contaminated with blood (even in quan- the late 1990s patients were usually given an entities too small to see) can result in HIV or hepatitis zyme-linked immunosorbent assay (ELISA) test B virus transmission. Sexual contact is a common for the presence of HIV antibody. Positive ELISA route of transmission from drug abusers to their sex results are then tested with a western blot assay for partners (who can transmit the virus to other sex confirmation. The polymerase chain reaction partners, other drug abusers, or to unborn chil- (PCR) test can be used to detect the presence of dren). Health-care workers have also been exposed nucleic acids from HIV in the very small number of to HIV through unprotected or accidental direct patients who have false-negative results on the contact with blood of infected patients in health- ELISA and Western blot tests. The use of these tests care settings. by blood banks has greatly reduced the chances of We do not knowhowmany individuals are HIV contracting infection from transfusions. infected worldwide. The World Health Organiza- Although a cure or vaccine for AIDS had not tion (WHO) estimated in 1995 that 18 million been discovered as of 2000, three groups of antivi- adults and 1.5 million children had been infected ral drugs are used to treat HIV infection. worldwide, producing about 4.5 million cases of 1062 SUBSTANCE ABUSE AND AIDS

AIDS. Most of these cases are in the developing came from large metropolitan areas; and that the countries of Asia and Africa. Numerous HIV sur- incidence of AIDS has slowly declined since 1996. veys have been conducted among injecting drug Needle Exchange Programs. Some investiga- abusers in several parts of the world. As those cur- tors recommend that injecting drug abusers employ rently HIV infected progress to AIDS, the health- ‘‘safer’’ needles and syringes. One approach to re- care systems and social fabric of many nations will duce HIV transmission among injecting drug abus- be severely challenged. ers is to educate addicts about cleaning needles and HIV does not appear to be contagious in other syringes between each use. Mechanical cleansing to settings. No known cases of AIDS have been linked remove any visible evidence of blood or other de- to transmission in nonsexual social or household bris in the paraphernalia is followed by rinsing with situations, through air, food, or water, or by mos- a disinfectant. Of the various disinfectants tested, quito bites. household bleach appears to be the most effective against HIV. Another approach has been the estab- PREVENTION AMONG DRUG ABUSERS lishment of needle/syringe exchange programs. Rigorous studies of the effects of such programs on Methadone Maintenance Treatment (MMT). (1) HIV transmission and (2) the recruitment of Because no reliable cure or vaccine for HIV infec- ‘‘new’’ injectors of drugs will help to show how tion exists now(nor is one expected to exist in the useful this strategy is. near future), the hope for slowing the spread of Newer Strategies. A more recent proposal HIV infection is through education and behavior- concerns evaluation of injecting drug abusers for changing strategies. Among injecting drug abusers, concurrent psychiatric disorders, particularly the most effective way to avoid HIV infection is to major depression and antisocial personality disor- stop sharing infected needles, or, better yet, stop der, as drug abusers with these disorders are at injecting drugs, and to avoid sexual contact with higher risk of HIV infection. Another strategy is the individuals who may be HIV-infected. Former drug extension of HIV prevention efforts to abusers of abusers in drug-abuse treatment have been consis- other drugs, most notably cocaine and amphet- tently found to have lower HIV infection rates than amines. Lastly, the high rates of HIV infection those on the streets. Methadone maintenance ther- among Native Americans and Spanish-speaking apy has been shown to be an effective therapy for drug injectors born outside the United States, re- opiate addicts and has decreased HIV transmission spectively, have led to concerted efforts to develop among compliant patients. As of 2000, the rates of group-specific interventions and to recruit outreach patient compliance among patients in maintenance workers from these affected groups. methadone treatment were higher among women than men; higher among Caucasians than among (SEE ALSO: Alcohol and AIDS; Complications: minorities; and higher among older than younger Route of Administration; Injecting Drug Users and patients. The National Institute on Drug Abuse HIV; Needle and Syringe Exchanges and HIV/ (NIDA) continues to conduct research on innova- AIDS; Sweden, Drug Use in) tive treatment for drug abuse. HIV Counseling. The use of HIV antibody BIBLIOGRAPHY tests, counseling about HIV infection, and partner notification projects in drug-abuse treatment pro- BALDWIN, J. A., ET AL. (1999). HIV/AIDS risks among grams have thus far met with limited success. A Native American drug users: key findings from focus Morbidity and Mortality Weekly Report issued in group interviews and implications for intervention June 2000 noted that men who have sex with men strategies. AIDS Education and Prevention, 11, and also abuse drugs (MSM/IDU) still pose unique (4) 279–292. challenges to slowing the AIDS epidemic because BATTJES, R. J., & PICKENS, R. W. (1988). Needle sharing they have multiple risks for HIV infection and among intravenous drug abusers: National and inter- transmission. The findings for the period 1985 to national perspectives. NIDA research monograph no. 1998 showthat over half of MSM/IDU withAIDS 80. Washington, DC: U.S. Government Printing Of- were non-Hispanic blacks and Hispanics; that most fice. SUICIDE AND SUBSTANCE ABUSE 1063

BEERS, M. H., & BERKOW, R. (EDS.) (1999). The merck SUDDEN INFANT DEATH SYNDROME manual of diagnosis and therapy, 17th ed. See Fetus: Effects of Drugs on; Tobacco: Medical Whitehouse Station, NJ: Merck Research Laborato- Complications ries. CENTERS FOR DISEASE CONTROL. (2000). HIV/AIDS SUICIDE AND SUBSTANCE ABUSE among men who have sex with men and inject With 29,000 annual victims, SUICIDE is the eighth drugs—United States, 1985–1998. Morbidity and leading cause of death in the United States. Alcohol Mortality Weekly Report 49, (21) 465–470. and illicit drugs are involved in about 50 percent of COMPTON, W. M. (2000). Cocaine use and HIV risk in all suicide attempts. About 25 percent of completed out-of-treatment drug abusers. Drug and Alcohol De- suicides occur among alcoholics and drug abusers. pendence, 58, (3) 215–218. Substance abuse among young adults is largely COMPTON, W. M., ET AL. (2000). The effects of psychiat- responsible for the increased suicide rates under ric comorbidity on response to an HIV prevention age thirty. intervention. Drug and Alcohol Dependence, 58, The relationship between substance abuse and (3) 247–257. suicidal behavior has been more extensively studied FREEMAN, R. C., WILLIAMS, M. L., & SAUNDERS,L.A. for alcoholism than for drug abuse. To evaluate this (1999). Drug use, AIDS knowledge, and HIV risk relationship, it is helpful to understand the statistical association between ALCOHOL and drug abuse behaviors of Cuban-, Mexican-, and Puerto-Rican- and suicide, to learn which substance abusers are at born drug injectors who are recent entrants into the particular risk to attempt or commit suicide, and to United States. Substance Use and Misuse, 34, 1765– appreciate howthis knowledgemay be used to pre- 1793. vent suicide. HAHN, R. A., ET AL. (1989). Prevalence of HIV infection among intravenous drug users in the United States. SUBSTANCE ABUSE INCREASES Journal of the American Medical Association, 261, SUICIDE RISK 2677–2684. HAVERKOS, H. W. (1989). AIDS update: Prevalence, pre- Suicides are not random; each occurs in a partic- vention, and medical management. Journal of Psy- ular context. The association between specific psychiatric syndromes—such as DEPRESSION or abuse choactive Drugs, 21, 365–370. of alcohol or drugs—and suicidal behavior has been ROTHERAM-BORUS, M. J., MANN, T., & CHABON,B. studied by epidemiologists using both retrospective (1999). Amphetamine use and its correlates among and prospective methods. Since interviews with sui- youths living with HIV. AIDS Education and Preven- cide completers are impossible, retrospective re- tion, 11, 232–242. views of the circumstances predating suicides have SAMBAMOORTHI, U., ET AL. (2000). Drug abuse, metha- been conducted. By using interviews of relatives and done treatment, and health services use among injec- others familiar with the suicide victim, together with tion drug users with AIDS. Drug and Alcohol Depen- study of medical records, suicide notes, and coroner dence, 60, (1) 77–89. reports, each suicide case is subjected to a ‘‘psycho- SELWYN, P. A. (1989). Issues in the clinical management logic autopsy.’’ Factors that distinguish successful of intravenous drug users with HIV infection. AIDS, suicide cases from suicide attempters and substance 3(suppl. 1), S201–S208. abusers who have never attempted suicide are compared in the hope that differences in these factors HARRY W. HAVERKOS may identify those at particular risk of attempted or D. PETER DROTMAN completed suicide. A limitation of retrospective REVISED BY REBECCA J. FREY studies is termed recall bias: informants may provide information about the suicide victim that is distorted by their attempt to explain the suicide SUBSTANCE ABUSE AND MENTAL event. Although written records and use of stan- HEALTH SERVICES ADMINISTRATION dardized methods to collect diagnostic information (SAMHSA) See U.S. Government Agencies can reduce this bias, prospective studies are more 1064 SUICIDE AND SUBSTANCE ABUSE reliable. Prospective studies in the general popula- young adults, actually attempt it. Among alcoholics tion are not feasible, because suicide is rare, occur- studied in the ECA communities, 32.5 percent had ring in only about 1 in 10,000 annually; however, attempted suicide during a period of active alcohol- about 10 percent of suicide attempters, 15 percent ism. About 15 to 25 percent of alcoholics in treat- of depressed people, and 3 percent of alcoholics ment programs report having previously attempted eventually commit suicide. By prospective study of suicide. In a group of treated opiate addicts, 17 such high-risk groups, additional risk factors can be percent had attempted suicide. This represents at identified during a follow-up period. least a fivefold increased frequency of suicide at- Although most heavy drinkers are not alcoholic, tempts compared to those among nonsubstance heavy drinking in young adulthood is associated abusers. with suicide in middle adulthood. A prospective Although only about 10 percent of substance study of Swedish military conscripts found that abusers who attempt suicide will die in a subse- those who drank more than twenty drinks weekly quent attempt, most substance abusers who com- had three times the death rate, prior to age forty, of mit suicide have attempted suicide at least once light drinkers. Most of these premature deaths were before. Thus, a reviewof the risks of suicide at- due to suicide or accidents. Those who develop tempts may guide the identification of those sub- alcohol dependence or abuse are, together with stance abusers at risk of suicidal death. The risk of drug abusers, at increased risk of death from acci- attempting suicide by an alcoholic or drug abuser is dents, liver disease, pancreatitis, respiratory dis- increased by coexisting depression, ANTISOCIAL ease, and other illnesses; however, suicide is among PERSONALITY disorder (ASP), and a history of pa- the most significant causes of death in both male rental alcoholism. and female substance abusers. U.S. and Swedish Even among people who do not abuse alcohol or prospective studies, for example, found that alco- drugs, major depression increases the risk of at- holism increased the risk of suicide fourfold in men tempting suicide. Major depression is itself 50 per- and twentyfold in women. cent more common among alcoholics than nonalco- Next to depression, alcoholism and drug abuse holics: it was found among 5 percent of male and are the psychiatric conditions most strongly associ- 19 percent of female alcoholics living in the five ated with suicide attempts. In the U.S. Epidemio- ECA communities. Depressive feelings (but not logic Catchment Area (ECA) Study conducted in the necessarily the syndrome of major depression) of- 1980s, the risk of suicide attempts was increased ten motivate alcoholics and drug addicts to enter a forty-onefold by depression and eighteenfold by treatment program. Typically 20 to 40 percent of alcoholism. While COCAINE users had increased alcoholics in such programs have had a period of rates of suicide attempts, users of MARIJUANA,SEDA- major depression during their lifetime. While many TIVE-HYPNOTICS, and AMPHETAMINES did not. people drink alcohol or use drugs such as cocaine to Among completed suicides, the proportion who reduce feelings of depression, experiments show were alcoholics or drug abusers is large: Prior to that consumption produces an initial state of eu- 1980, ALCOHOLISM accounted for about 20 to 35 phoria, followed within a few hours by anxiety, percent, and drug abuse for less than 5 percent, of depression, and enhanced suicide ideas. Retrospec- suicides in a variety of countries. In the San Diego tive studies have found that depressive symptoms Suicide Study, conducted in the early 1980s, well are more common among alcoholics who have over 50 percent of 274 consecutive suicides had made a suicide attempt. alcoholism or drug abuse or dependence. Much of Several studies have found that alcoholism in a the increase in young-adult suicide rates since the parent is associated with suicide attempts among 1960s is attributable to alcoholism and drug abuse alcoholics. In addition, antisocial personality disor- or dependence. der (ASP) and drug abuse, which commonly occur in genetically predisposed males who develop alcoholism early in life, are associated with suicide at- RISK FACTORS FOR tempts. Many clinicians have noted the repetitive SUICIDE ATTEMPTS high-risk behaviors of intravenous drug addicts, Alcoholics and drug abusers frequently threaten who often are quite aware that they may acquire to kill themselves. Many, particularly women and infection or die by overdose with each injection. SUICIDE AND SUBSTANCE ABUSE 1065

Overdoses occur more commonly among HEROIN especially those who talk of suicide, are at high risk addicts who have attempted suicide than among of suicide. those who have not. Highly impulsive and aggres- Long-term Use. Ongoing substance use makes sive alcoholics or drug abusers with ASP may be a suicide more likely. Nearly all alcoholic suicides subgroup at elevated risk of attempting suicide. occur among active drinkers, and alcohol con- Transient but intense dysphoria (feeling unwell or sumption often immediately precedes the suicide. unhappy), though not of sufficient scope or dura- The abstinent alcoholic is only partly protected tion to meet criteria for major depression, may from suicide, however, for 3 percent of suicides nonetheless increase this group’s risk of attempting among alcoholics occur among those who are absti- suicide. nent. It is likely that impulsiveness and transient or Prospective studies have found that depression, syndromal depression contribute to these suicides. anxiety, and histories of violence and legal prob- Psychiatric Conditions. Coexisting psychiat- lems were predictive of suicide attempts in previ- ric conditions, particularly depression, play an im- ously nonsuicidal drug addicts. Retrospective stud- portant and perhaps crucial role in the suicide of ies of alcoholics and drug addicts have found that alcoholics and drug abusers. The vast majority of poor social supports, occupational losses, personal suicide victims have depressive symptoms at the losses such as divorce, and other family problems time of their death. Concurrent depression is the leading factor in at least 50 percent of suicides increase their risk of making a suicide attempt. among alcoholics and drug abusers. SCHIZOPHRE- NIA, mania, and ASP are also associated with sui- RISK FACTORS FOR cide in substance abusers. COMPLETED SUICIDE Timing. What determines the timing of suicide Although in the general population there is con- among substance abusers? Substance abusers often siderable overlap between those who attempt sui- accumulate interpersonal problems throughout cide and those who complete suicide, substantial their drinking or drug-use careers, but one-third of differences exist between these groups. For exam- those who commit suicide sustain a major interper- ple, women are three times more likely than men to sonal disruption (such as separation or divorce) attempt suicide, while men are three times more within the six weeks preceding their deaths. They often are unemployed, living alone, and unsup- likely to commit suicide. Despite these differences, ported by family and friends at the time of this final suicide attempters are at higher risk of completed and most severe disruption. In contrast, only 3 suicide. What, then, are the risk factors for com- percent of nonalcoholics with depression suffer pleted suicide in substance abusers? such a loss in the period before they commit sui- Depression. Depressed people, particularly cide. Beyond psychiatric diagnoses, the strongest men, typically kill themselves in young adulthood. indicator of suicide risk in substance abusers is Among pure alcoholics, over 90 percent of suicides such an interpersonal loss. Beyond these actual occur among men. In contrast to depressives, alco- losses, anticipated losses, such as impending legal, holic men typically commit suicide in their fifth and financial, or physical demise may also increase the sixth decades; usually this follows about twenty risk of suicide among substance abusers. Among years of alcoholism. Men with depression, but not alcoholics, those who develop serious medical prob- those with alcoholism, continue to be at elevated lems, such as liver disease, pancreatitis, or peptic suicide risk beyond age sixty. Drug abuse shortens ulcers, are also at higher risk of suicide. the interval preceding suicide: in the San Diego Summary. Which of these risk factors is the Suicide Study, drug addicts committed suicide af- most important, and howdo they interact to affect ter an average of only nine years of heavy use. They the risk of suicide? To partly answer these ques- typically did so in young adulthood. This suggests tions, Murphy and colleagues studied 173 white that factors other than alcoholism may shorten the male alcoholics, 67 of whom committed suicide. suicide risk period in this group. About three of After adjusting for age, the most potent risk factor four alcoholic suicides communicate their suicidal for suicide was (1) current drinking, followed by intent prior to their deaths. Thus, middle-aged (2) major depression, (3) suicidal thoughts, male alcoholics and young polysubstance abusers, (4) poor social support, (5) living alone, and 1066 SURGEON GENERAL, REPORT OF THE

(6) unemployment. All suicide cases had at least (SEE ALSO: Accidents and Injuries; Complications: one, and 69 percent had at least four, of these six Mental Disorders; Epidemiology of Drug Abuse; So- risk factors. These factors act cumulatively to in- cial Costs of Alcohol and Drug Abuse) crease the risk of suicide in male alcoholics significantly. Their relative roles in other groups of sub- BIBLIOGRAPHY stance abusers have not been reported. ACTA PSYCHIATRICA SCANDINAVICA 81, 565–570. ALLEBECK, P., & ALLGULANDER, C. (1990). Suicide CLINICAL FEATURES among young men: Psychiatric illness, deviant behav- Substance abusers who commit suicide often see iour and substance abuse. a physician or are psychiatrically hospitalized in FOWLER, R. C., RICH, C. L., & YOUNG, D. (1986). San the months prior to their deaths. Those who talk of Diego suicide study, II: Substance abuse in young suicide may be ambivalent about their wish to die. cases. Archives of General Psychiatry, 43, 962–965. They may thus be amenable to clinical interven- HESSELBROCK, ET AL. (1988). Suicide attempts and alco- tions such as detoxification, substance-abuse reha- holism. Journal of the Study of Alcohol, 49, 436–442. bilitation, or psychiatric hospitalization. Con- MOSCIDKI,E.K.ET AL. (1992). Suicide attempts in the versely, those who take special precautions against epidemiologic catchment area study. Yale Journal of discovery during a prior suicide attempt are much Biological Medicine, 61, 259–268. more likely to die in a subsequent suicide attempt. MURPHY, G. E. (1992). Suicide in alcoholism. NewYork: Feelings of hopelessness are common in depres- Oxford University Press. sion. While suicide attempters who are depressed ROSEN, D. H. (1976). The serious suicide attempt: Five and who report hopelessness are more likely to die year follow-up study of 886 patients. Journal of the of suicide, hopelessness is not a particular risk for American Medical Association, 235, 2105–2109. completion of suicide among alcoholics. This may MICHAEL J. BOHN occur because substance abusers are motivated to commit suicide less by persistent hopelessness and more by impulsive anger, dysphoria, or feelings of SURGEON GENERAL, REPORT OF THE isolation or abandonment. See Tobacco: Medical Complications; Treatment: Tobacco PREVENTION Prediction of those who will complete suicide SWEDEN, DRUG USE IN Sweden is remains poor in individual cases, even among high- roughly the size of California—or twice that of the risk groups such as substance abusers. Despite their United Kingdom. Sweden’s capital city, Stock- high prevalence, alcoholism and drug abuse often holm, has a population of about 1.3 million, and go unrecognized by physicians and other health- the country as a whole has some 8.8 million inhabi- care professionals. Recognition of alcohol and drug tants. The first well-documented example of drug use disorders and of risk factors such as major abuse in Sweden arose during the 1940s, when the depression that increase the risk of suicide may technique of injecting AMPHETAMINE began to assist clinicians with preventive interventions. The spread among criminal elements and bohemians in substance abuser with active suicide plans or a Stockholm. This form of intravenous (IV) drug recent suicide attempt may need hospitalization, abuse quickly spread to other major towns and detoxification, and/or rehabilitation designed to cities and also to the neighboring countries of foster abstinence from alcohol and drugs of abuse. Finland, Norway, and Denmark. In 1944, central Firearms should be removed from the homes of nervous system (CNS) stimulants were subjected to substance abusers with active suicide ideation, es- the same strict prescription control regulations as pecially adolescents and young adults. Treatments narcotic drugs in general. In Sweden, CNS stimu- designed to enhance social supports and foster ab- lants were formally scheduled as narcotics in 1958. stinence from alcohol and drugs, together with The classification of CNS stimulants as psychotro- those directed at resolution of major depression, pic substances in the international convention of often reduce the risk of suicide. 1971 was largely a result of Sweden’s efforts. SWEDEN, DRUG USE IN 1067

MARIJUANA (Cannabis leaves), declared an illicit METHADONE MAINTENANCE treatment for opiate drug in Sweden in 1930, enjoyed its ﬁrst popularity addicts, using very strict admission criteria, is cur- around 1954, when the habit of smoking a ‘‘joint’’ rently available at three university hospital cli- was started by American jazz musicians who were nics—at Stockholm, Uppsala, and Malmo¨-Lund. performing in Sweden. HASHISH (Cannabis resin) Doping compounds, such as ANABOLIC STE- was introduced in the early 1960s and became ROIDS, are regulated under the Doping Compounds popular among young people as the habit of smok- Act of 1992. These substances cannot be imported, ing ‘‘pot’’ (marijuana) emerged along with the produced, traded, or possessed without special per- youth rebellion. In the 1990s, the domestic growing mits; however, use of anabolic steroids is not a of Cannabis plants started on a small scale. punishable offense at the present time. The intravenous use of heroin stems from the mid-1970s, and this mode of drug abuse quickly CURRENT SITUATION AND TRENDS attracted attention from the news media when several overdose deaths were reported. COCAINE was Since the 1970s, hashish has been the most introduced into Sweden in the late 1970s, but on a widespread of the illicit drugs used in Sweden; it is small scale. often considered the starting point, or gateway, into abuse of other drugs. During the screening of job applicants in 1986, as many as 4 percent had traces LEGISLATION of TETRAHYDROCANNABINOL (THC) in their urine. In Sweden, the term narcotic drugs refers to all An estimated 50,000 people regularly smoke hash- pharmaceutical substances controlled under the ish in Sweden as of the mid-1990s. A study con- provisions of the Narcotic Drugs Act (1968) and ducted by UNO (Utredningen om narkotika- listed on the Narcotic Drug Schedules issued by the missbrukets omfattning, or Commission on the Ex- Swedish Medical Products Agency. These schedules tent of Drug Abuse) in 1979 revealed somewhere contain all internationally controlled substances between 10,000 and 14,000 severe drug abusers, and some additional substances, such as KHAT or tung missbrukare, that is, users who take drugs (leaves and branches from Catha edulis). The use either on a daily basis or intravenously, exclusive of of Schedule I drugs (Cannabis, LSD, HEROIN, frequency. A similar study in 1992 found this num- MDMA, khat, etc.) is prohibited, even for medical ber had increased to between 14,000 and 20,000. purposes. Amphetamine, which is relatively easily ob- Narcotic offenses in Sweden fall into three tained throughout the country, is the most popular classes: drug of abuse for intravenous use; about 10,000 people are currently using this CNS stimulant. In- 1. Petty offenses involving possession of small jection of heroin seems to be mainly concentrated amounts of the drug punishable with a ﬁne or in the southern and central metropolitan areas, imprisonment for a maximum of six months. where some 2,000 to 3,000 are known to indulge in 2. Narcotic offenses, which might entail selling this form of drug abuse. The abuse of cocaine is (‘‘pushing’’) drugs on the streets, carry a maxi- primarily seen within jetset circles in the major mum of three years imprisonment. cities. The smoking of CRACK-cocaine is uncom- 3. Grave (serious) narcotic offenses, such as the mon in Sweden. HALLUCINOGENS (such as LSD and import of large amounts of illicit drugs or the Ecstasy) are used to some extent by adolescents production and sale of narcotics. These offenses who follow the ‘‘rave’’ culture. Plant hallucinogens are punishable by imprisonment for two to ten such as PSILOCYBIN are rarely encountered, as are years. PHENCYCLIDINE (PCP), ‘‘ice’’ (crystallized Compulsory (coercive) treatment of drug abus- METHAMPHETAMINE) and phentanyl (e.g., fentanyl, ers is allowable under the 1988 law for Treatment sufentanil) opioids. Solvent (inhalant) abuse is on of Alcoholics and Drug Misusers. Young offenders the rise in Sweden, with 10 percent of 16-year-old may be subjected to compulsory treatment under boys and 6 percent of 16-year-old girls reporting the Care of Young Persons Act of 1990. The deci- usage in 1999. Those who use this type of product sion to invoke this treatment for young drug abus- for the purpose of intoxication can be treated under ers is made by the county administrative courts. the Care of Young Persons Act or the Care of 1068 SWEDEN, DRUG USE IN

Alcoholics, Drug Abusers and Abusers of Volatile project rapidly became unmanageable; it was Solvents (Special Provisions) Act. stopped as the IV drug habit began to spread Increased immigration into Sweden during the widely and several fatal overdoses were reported. 1980s brought the development of newsubpopula- During the final twelve months of the project, the tions of drug users, with use patterns derived from prevalence of IV drug use among the arrestee popu- their home drug cultures. These included the smok- lation in Stockholm had doubled. ing of opium and heroin, which is common to the In 1969, a nationwide police offensive against Middle East, or the chewing of khat from East all sorts of drug-related crime brought about a Africa. The relaxing of border controls with the dramatic decrease in drug abuse in Sweden. The Eastern bloc led to newsmuggling routes for drugs tendency among public prosecutors to dismiss petty into Sweden—hashish from Russia and amphet- drug offenses during the 1970s led to an escalation amine from Poland. in drug abuse once again. Since 1980, all drug According to figures obtained from the Stock- offenses have been either referred to the courts for holm Remand Prisons, human immunodeficiency trial or, if the suspects plead guilty to petty of- virus (HIV) infection rates in the early 1990s were fenses, they are fined directly. In the late 1980s, the approximately 30 percent among IV abusers of police began a newstrategy against drug abuse, by heroin and 5 percent among IV abusers of amphet- focusing more attention on all kinds of drug activ- amine. About 600 individuals are apprehended ity on the streets—with the aim of decreasing the each year in Sweden on suspicion of driving under demand for drugs. the influence of drugs. The most common drug The fight against drug abuse in Sweden grew encountered in people suspected of driving under progressively stricter between 1983 and 1993. In the influence of narcotics is amphetamine, followed 1988, the taking of illicit drugs was made a by Cannabis and then various SEDATIVE-HYPNOTIC punishable offense. Since July 1, 1993, the police prescription drugs belonging to the BENZODIAZE- have been allowed to order chemical analyses of PINE family. body fluids for evidence that a suspect has been Annual studies of drug use by school children taking illicit drugs. The primary goal of Swedish (aged 16) and military conscripts (aged 18) have drug policy is to establish and maintain a narcot- been conducted in Sweden for some time by CAN, ics-free Sweden. Measures employed in this effort the Swedish Council for Information on Alcohol include information campaigns (prevention), strict and Other Drugs. In 1998, CAN reported that 9 border controls to minimize smuggling, mandatory percent of 16-year-old boys and 6 percent of 16- treatment programs for offenders, street-level in- year-old girls had tried drugs, a number roughly terventions, and legal restrictions on sale, use, and double that reported in 1991. Among the military production of drugs. Sweden’s drug policy is often conscripts, 16 percent reported having experi- held up as model for other European nations, but mented with drugs at least once, up from 6 percent has recently come under attack by those alarmed in 1991. Two-thirds of those who reported having by the steady increase in drug use despite these tried drugs had used only cannabis, with amphet- strict controls. amine following as the second most-tried drug. (SEE ALSO: Amphetamine Epidemics; Britain, Drug SHIFTS IN CONTROL POLICY Use In; Drug Testing and Analysis; Italy, Drug Use in; Netherlands, Drug Use in the) Sweden has experienced dramatic shifts in public policy concerning the control of illicit drugs. In BIBLIOGRAPHY 1965, after a turbulent media campaign, the medical authorities were obliged to allow certain doctors BEJEROT, N. (1975). Drug abuse and drug policy. Acta to prescribe what were illicit drugs to registered Psychiatrica Scandinavica, Supplement 256. addicts for their personal use, as part of the BEJEROT, N. (1970). Addiction and society. Springfield, so-called legal prescription experiment. Over a IL: Charles Thomas. two-year period, about 4 million doses of amphet- SWEDISH COUNCIL FOR INFORMATION ON ALCOHOL AND amine and 600,000 doses of morphine had been OTHER DRUGS (CAN). (1999). Trends in alcohol and distributed to a total of only 150 addicts. The drug abuse in Sweden, Report 99. Stockholm: CAN. SYNAPSE, BRAIN 1069

SWEDISH NATIONAL CRIME PREVENTION BOARD. (1990). SYNAPSE, BRAIN The term synapse is Current Swedish legislation on narcotics and psycho- from the Greek word synaptein, for ‘‘juncture’’ or tropic substances, 2. Stockholm: Allma¨nna Fo¨rlaget. ‘‘fasten together,’’ by way of the Latin synapsis.It SWEDISH NATIONAL POLICE BOARD. (1992). Narcotic refers to the specialized junction found between drugs, laws, facts, arguments. Stockholm: Allma¨nna nerve cells. It was conceived by the British pioneer Fo¨rlaget. neurophysiologist Sir Charles Sherrington (1857– JONAS HARTELIUS 1952) to describe the then-novel microscopic ob- A. W. JONES servations that the ‘‘end-feet’’ of one neuron physi- REVISED BY SARAH KNOX cally contacted, in an intimate manner, other NEU-

Figure 1 Synapse. The nerve ending from one neuron forms a junction, the synapse, with another neuron (the postsynaptic neuron). The synaptic junction is actually a small space, sometimes called the synaptic cleft. Neurotransmitter molecules are synthesized by enzymes in the nerve terminal, stored in vesicles, and released into the synaptic cleft when an electrical impulse invades the nerve terminal. The electrical impulse originates in the neuronal cell body and travels down the axon. The released neurotransmitter combines with receptors on postsynaptic neurons, which are then activated. To terminate neurotransmission, transporters remove the neurotransmitter from the synaptic cleft by pumping it back into the nerve terminal that released it. SOURCE: Figures 1 and 2 have been modiﬁed from Figure 1, in M. J. Kuhar’s ‘‘Introduction to Neurotransmitters and Neuroreceptors,’’ in Quantitative Imaging, edited by J. J. Frost and H. N. Wagner. Raven Press, NewYork, 1990. 1070 SYNAPSE, BRAIN

Figure 2 Neuronal Network. Synapses can be seen here with their narrow synaptic clefts, only 20 micrometers wide, across which a nerve impulse is transmitted from one neuron to the next. Hundreds of thousands of nerve endings may form synapses on the cell body and dendrites of a single neuron. As an electrical impulse reaches the synaptic cleft, it cannot be transmitted because of a discontinuation in the cell membrane. To bridge this cleft, another type of transmission, a chemical transmission, begins, mediated by a chemical compound—the transmitter substance or a neurotransmitter.

RONS to which it was structurally connected. A membrane termed the active zone and believed to similar point of connection between peripheral be the site of initial response. nerves and their targets is usually referred to as a The synaptic vesicles have been shown to conjunction. tain the NEUROTRANSMITTERS by a series of exten- Synapses in the brain (see Figures 1 and 2) are sive analyses of meticuously purified vesicles. The morphologically typed by several features (1) a di- vesicles differ in their protein content and may lation of the presynaptic terminal (nerve ending) include the transmitter’s synthetic enzymes, as well as the transporters that can concentrate the trans- that contains accumulations of synaptic vesicles in mitter within the vesicles. For MONOAMINE neurons, various sizes, shapes, and chemical reactivities; the vesicles also contain specific proteins (named (2) mitochondria; (3) a specialized zone of modi- for their sites of discovery in the adrenal medulla as fied thickness and electron opacity in the presyn- chromogranins but nowtermed more generally se- aptic membrane, in which a presynaptic grid is cretogranins. These are assumed to facilitate stor- perforated to provide maximum access of transmit- age and release. Superficially, synapses with a thin- ter-containing vesicles to the presumptive sites of ner postsynaptic specialization, of about the same transmitter release; and (4) a specialized zone of thickness as that at the presynaptic membrane altered thickness and opacity in the postsynaptic (hence termed symmetrical ), are often inhibitory; SYRINGE EXCHANGE AND AIDS 1071 those with a thickened postsynaptic membrane they include the postsynaptic receptors and associ- (asymmetrical ) are often excitatory. ated molecules that can transduce the signals from Monoaminergic synapses, however, are often the activate receptors, as well as those molecules asymmetrical, as are those for peptide-containing that serve to concentrate the receptors in such loca- neurons that do not obey these simple physiological tions. categorizations. Synapses can also be discriminated on the basis of the pairs of neuronal structures that (SEE ALSO: Brain Structures and Drugs; Neuro- come together at this site of functional transmis- transmission; Reward Pathways and Drugs) sion. Most typical is the axo-dendritic synapse in which the axon of the presynaptic neuron contacts BIBLIOGRAPHY either the smooth or spiny surface of the dendrite of the post-synaptic neuron. A second common form BLOOM, F. E. (1990). Neurohumoral transmission in the is the axo-somatic synapse in which the presyn- central nervous system. In A. G. Gilman et al. (Eds.), aptic axon contacts the surface of the post-synaptic Goodman and Gilman’s the pharmacological basis of neuron’s cell body (or somata). Less frequently therapeutics, 8th ed. Pergamon. observed are axo-axonic relationships in which one COOPER, J. C., BLOOM, F. E., & ROTH, R. H. (1991). The axon contacts a second axon-terminal that is in its biochemical basis of neuropharmacology, 6th ed. own axo-dendritic relationship; such triads of axo- NewYork: Oxford University Press. axo-dendritic synapses are found most frequently FLOYD BLOOM in spinal cord and certain midbrain structures, in which channels of information flow are necessarily highly constrained. Most rarely, junctions between SYNANON See Treatment Programs/Cen- cell bodies (somato-somatic) and dendrites (den- ters/Organizations: An Historical Perspective dro-dendritic) have also been described. The nature of the proteins that provide for the thickened appearances of the active zones by elec- SYRINGE EXCHANGE AND AIDS See tron microscopy are not completely known, but Needle and Syringe Exchanges and HIV/AIDS T

TASC See Treatment Alternatives to Street tax collections and was still as high as 10 percent on Crime the eve of U.S. entry into World War II. Currently, the federal excise taxes and import duties continue to have a considerable effect on the prices of alco- TAX LAWS AND ALCOHOL The first in- holic beverages, but figure very lightly (less than ternal revenue measure adopted by the U.S. Con- 1%) in overall federal tax collections. gress, in 1790, was an excise tax on domestic whis- Because federal excise taxes are set in dollar key; a subsequent increase in that tax from 9 to 25 terms per unit of liquid, rather than as a percentage cents per gallon led to an armed insurrection by the of the price, inflation gradually erodes the real farmers of western Pennsylvania during the sum- value of these taxes. For example, while Congress mer of 1794, the so-called Whiskey Rebellion. increased the tax per fifth of 80-proof spirits by 29 This matter of the appropriate level for alcoholic percent (to $2.16) between 1951 and 2000, the beverage taxes has remained contentious to this overall level of consumer prices increased by over day; although there is consensus that alcoholic bev- 550 percent during this same period. The result is erages should be subject to higher taxes than other that the real value of the federal liquor tax had commodities, substantial disagreement remains declined by 2000 to just one-fifth of its value in concerning the appropriate level for such taxes. 1951. A considerable reduction in the average price The principal impetus for raising tax rates has al- of whiskey and other spirits relative to the prices of ways been the quest for increased government reve- other commodities has been the inevitable result. nue. Since the 1970s, however, increasing attention The states also impose special excise taxes on has been paid to the public health benefits of alco- alcoholic beverages, as do some local governments. hol taxes, as research has demonstrated that raising In addition, alcoholic beverages are generally sub- the excise tax rates, and hence the prices of alco- ject to state and local sales taxes. The relative im- holic beverages, reduces traffic fatalities and other portance of these tax collections in state budgets costly consequences of alcohol abuse. differs widely, but as of 2000 is everywhere less than 10 percent of government revenues. HISTORY TAX EFFECTS Alcoholic beverage taxes were a major source of revenues for the federal government throughout When a legislature raises the excise tax rates on much of U.S. history. As recently as 1907, this alcoholic beverages, the resulting cost to distribu- source accounted for 80 percent of federal internal tors is passed along to consumers in the form of

1073 1074 TAX LAWS AND ALCOHOL higher prices. As is true for other commodities, the violent crime—and the harms resulting from sales of alcoholic beverages tend to fall when prices chronic heavy drinking, most notably the long- increase. This is not to say that price is all that term deterioration in health and productivity. matters. For example, the steady decline in sales There is considerable evidence that the inci- and consumption of alcohol during the 1980s can- dence of both inebriation and chronic heavy drink- not be explained by increased prices, since the ing, and the associated harms, are sensitive to the prices of alcoholic beverages remained more or less prices of alcoholic beverages. For the acute effects, constant (in real terms) during this period. The Cook (1981) studied 39 instances in which states downward trend in consumption presumably re- increased their liquor tax between 1960 and 1975, sulted from the aging of the population and in- finding strong evidence that traffic fatalities in creasing public concern with healthy lifestyles, those states fell as a result. This result was con- among other factors. Per capita sales and consump- firmed for the beer excise tax by Ruhm (1996) and tion of alcohol are nevertheless negatively affected Saffer & Grossman (1987), both using panel data by alcohol beverage prices, and if Congress had on state traffic fatality rates. Cook & Moore (1993), increased federal excise taxes substantially during also using panel data on states, found a close link the 1980s, sales would have declined still more between per capita ethanol consumption and vio- rapidly than they did. lent crime rates, and direct evidence that an in- Although they differ somewhat, a number of crease in the beer tax helped suppress rape and published estimates of the price elasticity of de- robbery. And, Chesson et al. (2000) use a similar mand for beer, wine, and liquor tend to confirm method to demonstrate that the incidence of sexu- that price is one of the important variables influ- ally transmitted disease is inversely related to the encing sales. One reviewof these estimates con- beer tax. This literature is not without dissenters cluded that the price elasticity for liquor is approxi- (see Dee, 1999), but the bulk of the published mately -1.0; this implies that, other things being research results provide support for the conclusion equal, a percentage increase in the average price of that alcohol excises influence the incidence of ine- liquor will result in an equal percentage reduction briation and the costly consequences thereof. in the quantity of liquor sold. Beer and wine sales There is also evidence of a link between alcohol tend to be somewhat less responsive to price, with prices and the prevalence of chronic heavy drink- estimated price elasticities in the neighborhood of ing. Cook & Tauchen (1982) demonstrated that -0.5 (Leung & Phelps, 1993). Estimates for other changes in state liquor taxes had a statistically developed countries are quite consistent with these discernible effect on the mortality rate from cirrho- conclusions (Edwards et al., 1994; Cook & Moore, sis of the liver. Since a large percentage of liver 2000). cirrhosis deaths result from many years of heavy These results do not in themselves imply that a drinking, it appears that chronic heavy drinkers are general price increase for alcoholic beverages will quite responsive to the price of alcohol. This con- reduce consumption of ethyl alcohol (ethanol), the clusion is supported by evidence from clinical ex- intoxicating substance in all these beverages. In the periments and other sources (Vuchinich & Tucker, face of higher prices, consumers can switch to 1988). higher- proof brands, reduce wastage, and attempt Thus, there is indeed evidence that alcohol taxes home production of beer or wine. But in practice, are an effective instrument for preventing alcohol- research suggests that these substitutions are not related harms. The claim that alcohol taxes pro- large enough to negate the price effect. Ethanol mote the public health is increasingly important in consumption does tend to fall in response to a gen- the public debate over raising federal and state eral increase in the price of alcoholic beverages. alcohol taxes. Given the fact that higher alcohol excise taxes increase prices and reduce ethanol consumption, FAIRNESS there remains the vital question of whether alcohol taxes are effective instruments in preventing alco- Although alcohol taxes reduce consumption and hol-related harms. Of public concern are both the save some lives that would otherwise be lost to harms associated with the acute effects of ine- alcohol-related accidents, there remains a question briation—injuries stemming from accidents and of whether they are ‘‘fair.’’ Fairness is largely in the TAX LAWS AND ALCOHOL 1075

eye of the beholder (or taxpayer); nevertheless, sev- BIBLIOGRAPHY eral standards are commonly used as bases for CHESSON, H., HARRISON, P., & KASSLER, W. J. (2000). judging the fairness of a tax. Two of the most Alcohol, youth, and risky sex: The effect of beer taxes notable standards are that a tax should fall equally and the drinking age on gonorrhea rates in teenagers on households which are in some sense equally and young adults. Journal of Law & Economics, 43, situated, and that it should not be regressive. 215-238. If equals are to be treated equally, is it fair that COOK, P. J. (1981). The effect of liquor taxes on drink- alcohol taxes force drinkers to pay more taxes than ing, cirrhosis, and auto fatalities. In M. H. Moore and nondrinkers of similar incomes? Indeed, the bulk of D. R. Gerstein (Eds.), Alcohol and public policy: Be- all alcohol taxes are paid by the small minority who yond the shadow of prohibition, 255-285. Washing- drink heavily: Half of all alcohol consumption is ton, DC: National Academy Press. accounted for by just 6 or 7 percent of the adult COOK, P. J., & MOORE, M. J. (1993). Economic perspec- population. One response is that it is fair for drink- tives on alcohol-related violence. In S. E. Martin ers to pay more, because drinking imposes costs on (Ed.), Alcohol-related violence: Interdisciplinary per- others. One estimate suggests that drinkers impose spectives and research directions. NIH Publication an average cost on others amounting to about 25 No. 93-3496. Rockville, MD: National Institute on cents per drink (Manning et al., 1990); Miller et al. Alcoholism and Alcohol Abuse. (1998) provide a much higher estimate. Thus, if COOK, P. J., & MOORE, M. J. (1993). Taxation of alco- the alcohol tax is considered a sort of ‘‘user fee,’’ holic beverages. In M. Hilton and G. Bloss (Eds.), whereby the drinker pays in proportion to the Economic research on the prevention of alcohol-re- amount of alcohol consumed, then it may seem fair. lated problems. NIH Publication No. 93-3513. Rock- Another concern is that alcohol taxes may be ville, MD: National Institute on Alcoholism and Alco- regressive, meaning that on the average, wealthier hol Abuse. households spend a smaller fraction of their income COOK, P. J., & MOORE, M. J. (2000). Alcohol. In A. J. on alcohol taxes than poorer households. Although Culyer and J. P. Newhouse (Eds.), Handbook of it is often taken as self-evident in political debates health economics, Vol. I. NewYork: Elsevier Science over raising beer taxes, the evidence on this matter B.V. 1–41. is not clear (Sammartino, 1990; Cook & Moore, COOK, P. J., & TAUCHEN, G. (1982). The effect of liquor 1993). taxes on heavy drinking. Bell Journal of Economics, Another debated issue is that of uniform taxa- Autumn, 13, 379–390. tion. A can of beer, a glass of wine, and a shot of DEE, T. S. (1999). State alcohol policies, teen drinking spirits all contain approximately the same amount and traffic fatalities. Journal of Public Economics, 72, of ethanol, but are taxed quite differently; the fed- 289–315. eral excise tax on a shot of spirits exceeds the tax on EDWARDS, G., ET AL. (1994). Alcohol policy and the pub- a can of beer by a factor of 2, and on a glass of wine lic good. NewYork: Oxford University Press. by a factor of 3. If special taxes on alcoholic bever- GROSSMAN, M. (1989). Health benefits of increases in ages are ultimately justified by the fact that such alcohol and cigarette taxes. British Journal of Addic- beverages are intoxicating, then these disparities tion, 84, 1193–1204. are difficult to explain. Part of the explanation may HU, T. Y. (1950). The liquor tax in the United States be the widespread belief that spirits are in some 1791–1947. NewYork: Columbia University Press. sense more intoxicating than beer or wine, and LEUNG,S.F,&PHELPS C. (1993). The demand for alco- hence more subject to abuse, whereas beer is the holic beverages. In M. Hilton and G. Bloss (Eds.), ‘‘drink of moderation’’ and wine ‘‘the drink of con- Economic research on the prevention of alcohol- noisseurs.’’ But much of the evidence works against related problems. NIH Publication No. 93-3513, 1- this view. Indeed, beer consumption may be more 31. Rockville, MD: National Institute on Alcoholism costly to society (per drink) than spirits because of and Alcohol Abuse. the demographics of beverage choice: young men, a MANNING, W.G., ET AL. (1991). The costs of poor health group that consumes most of their ethanol in the habits. Cambridge, MA: Harvard University Press. form of beer, has by far the highest incidence of MILLER, T.R, LESTINA D. C., & SPICER R. S. (1998). alcohol-related traffic accidents and violent crimes. Highway crash costs in the United States by driver 1076 TEA

age, blood alcohol level, victim age, and restraint use. Accident Analysis and Prevention, 30(2), 137–150. POGUE, T. F., & SGONTZ, L. G. (1989). Taxing to control social costs: The case of alcohol. American Economic Review, 79: 235–243. RUHM, C. J. (1996). Alcohol policies and highway vehicle fatalities. Journal of Health Economics, 15: 435–454. SAFFER, H., & GROSSMAN, M. (1987). Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Jour- nal of Legal Studies, 16: 351–374. SAMMARTINO, F. (1990). Federal taxation of tobacco, alcoholic beverages and motor fuels. Congresssional Budget Office Report. Washington, DC: U.S. Govern- Figure 1 ment Printing Office. Tea VUCHINICH, R. E., & TUCKER, J. A. (1988). Contributions from behavioral theories of choice to an analysis of that can affect mood and performance of adult alcohol abuse. Journal of Abnormal Psychology, 97 humans. (2), 181–195. Although the term tea has been used to refer to PHILIP J. COOK extracts from a large number of plants, only teas derived from leaves of Camellia sinensis plants are of special interest here, because they contain caffeine. The term tea has come to be used especially TEA Tea is the most widely consumed bever- for extracts of Camellia sinensis and that restricted age in the world, except for water, and provides usage is maintained in this entry. over 40 percent of the world’s dietary CAFFEINE.In Consumption of Camellia sinensis was first doc- the United States, caffeine from tea accounts for umented in China (where tea is called cha or chai) about 17 percent of caffeine consumed; per capita in 350 A.D., although there is some suggestion that caffeine consumption from tea is about 35 milli- the Chinese consumed tea as early as 2700 B.C. Tea grams per day, which is a little over one-third of the was introduced to Japan around 600 A.D. but did daily caffeine provided by coffee beverages. Tea not become widely used there until the 1400s. consumption in the United Kingdom is substan- Through the China trade, tea became available in tially higher, averaging 320 milligrams per capita England in the 1600s, where it became the national per day and accounting for 72 percent of the United drink. Tea was introduced into the American colo- Kingdom’s caffeine consumption. nies around 1650 but in 1773 became a symbol of Although tea contains a large number of chemi- British rule. Americans protested the British tax on cal compounds, the relatively high content of poly- tea by raiding ships anchored in Boston Harbor and phenols and caffeine is responsible for tea’s phar- dumping boxes of tea into the water. This event, macological effects. The primary psychoactive referred to as the Boston Tea Party, along with component of tea is caffeine. Tea also contains two other similar protests that followed, became impor- compounds that are structurally related to caffeine, tant in shifting the predominant caffeinated bever- theophylline and THEOBROMINE, however, these age in North America from tea to coffee. compounds are found in relatively insignificant India, China, and Sri Lanka are the major pro- amounts. On average, a 6-ounce (177-milliliter) ducers and exporters of tea—producing about 60 cup of leaf or bag tea contains about 48 milligrams percent of the world’s tea and providing about 55 of caffeine, a little less than half the caffeine in the percent of world tea exports. The United Kingdom, same amount of ground roasted coffee, and only the United States, and Pakistan are the leading slightly more than the amount found in 12 ounces importers of tea. of a typical COLA soft drink. Six ounces of instant Two types of tea, black and green tea, account tea contain 36 milligrams caffeine, on average. In- for almost all of the tea consumed in the world. dividual servings of tea contain amounts of caffeine Black tea makes up over 75 percent of the world’s TEMPERANCE MOVEMENT 1077 tea; green tea accounts for about 22 percent. The strategies used by the proponents changed from method by which tea is manufactured determines persuasive efforts to moderate the intake of alco- whether black or green tea is produced. Black tea is holic beverages to more coercive strategies, even dark brown in color and is produced by promoting laws, to bring about the control of all drinking. oxidation of a key tea constituent. Green tea is yellow-green in color and is produced by preventing EARLY PHASE: 1800–1840 such oxidation, a less processed tea. Oolong tea, a less common type, is partially oxidized and is inter- In colonial America and during the early 1800s, mediate in appearance to that of black and green alcoholic beverages (brewed, fermented, and dis- tea. Flavored teas were originally prepared by add- tilled) were a staple of the American diet, were ing a range of fruits, flowers, and other plant sub- often homemade, and were viewed as ‘‘the good stances to the tea prior to final packaging, although creature of God.’’ Among the colonists, the drink- artificial flavors are often added today. ing of alcoholic beverages was integrated with social norms; all social groups and ages drank alcoholic beverages, and the consumption rate was very (SEE ALSO: Chocolate; Plants, Drugs from) high. Alcohol was also traded, sold, and given to Native Americans, who had no long history of daily BIBLIOGRAPHY drinking, with almost immediate negative conse- BARONE, J. J., & ROBERTS, H. (1984). Human consump- quences for these peoples. tion of caffeine. In P. B. Dews (Ed.), Caffeine. New By 1840, a revolution in American social atti- York: Springer-Verlag. tudes had occurred, in which alcohol came to be SPILLER,G.A.(ED.). (1984). The methylxanthine bever- seen as ‘‘the root of all evil’’ and the cause of the ages and foods: Chemistry, consumption, and health major problems of the early republic, such as the effects. NewYork: Alan R. Liss. crime, poverty, immorality, and insanity of the Jacksonian era (Tyrell, 1979). Temperance was KENNETH SILVERMAN advocated as the ideal solution for these problems ROLAND R. GRIFFITHS by such people as Anthony Benezet, a popular Quaker reformer; Thomas Jefferson; and Dr. Ben- jamin Rush, the surgeon general of the Continental TEMPERANCE MOVEMENT Many Army and a signer of the Declaration of Indepen- temperance movements and societies emerged in dence. Temperance-reform organizations, such as the United States during the nineteenth century. the American Temperance Society, emerged, com- These movements began in the early 1800s and mitted to the eradication of these social problems. gained ascendancy during the mid-to-late 1800s, The American Temperance Society (ATS), culminating in the Prohibition Movement, the Pro- founded in Boston in 1826 as the American Society hibition Amendment (Article 18) to the U.S. Con- for the Promotion of Temperance, was the first stitution in 1919, and the start of Prohibition in national (as opposed to local) temperance organi- 1920. Gusfield (1986), an eminent scholar of the zation. It had its roots in the processes of industrial- temperance movement, has argued that the term ization and the commercialization of agriculture. temperance is not appropriate, because the broad The people who developed the movement were reformist ideology of the movement focused mainly committed to hastening the processes of economic on abstinence—not moderation—in the intake of and social change. These processes involved the alcoholic beverages. Blocker (1989) observed that educating of Americans to value sobriety and in- the many temperance movements that emerged in dustry, in order to create the conditions for the the United States represented men and women development of an industrial-commercial society. from varying ethnic, religious, social, economic, The movement was supported by entrepreneurs and political groups who selected out temperance who needed a disciplined and sober work force to as the solution to what they perceived as problems help create the economic change necessary for the in their own lives and in those of others. By the end material improvement of the young republic. of the nineteenth century, the temperance move- During the so-called Great Awakening the evan- ment had evolved through several phases, and the gelical clergy as well as that of other U.S. Protestant 1078 TEMPERANCE MOVEMENT groups supported temperance as a means of promoting the morality needed for building a ‘‘Chris- tian nation,’’ through social and economic progress. According to Gusfield, these groups helped to place the issue of drinking on the public and political agenda, providing their personnel as authorities on the cognitive aspects of drinking and becoming the legitimate source of public policies on drinking. Also, in the early 1820s and 1830s, small-scale farmers and rural groups were active in promoting the temperance movement; they sawtemperance as a way to promote social progress in a time of transition from a rural to an urban-industrial order, from small-scale farming to entrepreneurial forms of agriculture. By 1836, the American Temperance Society had become an abstinence society, and ideas about problems associated with alcohol had begun to A woodcut dating to the early phase of the change—inebriety or habitual drunkenness was temperance movement illustrates the physical being called a disease. The ideology of the move- and moral afflictions attributed to alcohol. Circa ment placed the source of alcohol addiction in the 1820. ( Bettmann/CORBIS) substance itself—alcohol was inherently addicting—a finding supported by research con- working-class drunkards who were trying to ducted by Rush, who in 1785 wrote Inquiry into the reform. Effects of Ardent Spirits upon the Human Body and In 1840, the (first) Washingtonian Temperance Mind (approximately 200,000 copies were pub- Society was established in Baltimore. Members lished between 1800 and 1840). Blocker (1989) took a pledge against the use of all alcoholic bever- observed that the general focus of the American ages and attempted to convert drunkards to the Temperance Society was on persuading the already pledge of teetotalism (c. 1834, derived from total temperate to become abstinent, rather than per- total abstinence). By the end of 1841, Wash- suading drunkards to reform their drinking behav- ingtonian societies were active in Baltimore, Bos- ior. According to Gusfield (1986), abstinence be- ton, NewYork, and other areas throughout the came a symbol that enabled society to distinguish North. These groups were not socially homoge- the industrious, steady American worker from neous. Tyrell (1979) observed that the relation- other people—which resulted in the movement be- ships between the old organizations and the new coming democratized instead of associated only societies culminated in various struggles for control with the New England upper classes. Attempts to over the Washingtonian societies, with fragmenta- reform and save drunkards was the focus of an- tion of these groups occurring. other temperance movement, the Washingtonians. Washingtonian members who wanted respect from the middle-class temperance reformers, in- MIDDLE PHASE: 1840–1860 cluding the evangelical reformers, elected to remain Where well-to-do groups and Protestant evan- with the mainstream temperance movement. The gelical clergy dominated the early phase of temper- wage earners and reformed drunkards remained in ance reform, the middle phase included the efforts their own societies, and they opposed early efforts of artisans and women of the lower and lower- at legal coercion—for example, the passage of the middle classes, who promoted self-help groups Maine Lawof 1851. Gusfield (1986) has inter- among largely working-class drunkards trying to preted support for this lawas a reaction against the give up drinking (Tyrell, 1979). These artisans drinking practices of the Irish and German immi- organized into the Washingtonian societies (named grants to the United States between 1845 and for George Washington), dedicated to helping 1855. He argued that temperance reform in this TEMPERANCE MOVEMENT 1079 period represented a ‘‘symbolic crusade’’ to impose WCTU was unsuccessful in establishing these alli- existing cultural values on immigrant groups. ances, it did achieve the following: It united the Tyrell interpreted the Maine Lawas a wayfor Populist and more conservative wings of the move- middle-class reformers to control and reform the ment and it united the political forces of ‘‘conser- laboring poor. From 1851 on, many local laws were vatism, progressivism, and radicalism in the same passed that attempted to limit the consumption of movement.’’ In addition, the WCTU provided alcohol; however, throughout the remainder of the backing for Prohibitionist candidates, including century, these statutes were repealed, liberalized, workers for their campaigns as well as audiences to or unenforced. listen to their positions on alcohol use. The WCTU still exists, based in Evanston, Illinois, and lists LATE PHASE: 1860–1920 about 100,000 members as of 1990. By the late 1800s, coercive reform became the The Civil War, World War I, and the rapid de- dominant theme of the temperance movement. In mographic changes that accompanied immigration 1893, the ASL of Ohio was organized by Howard during this period contributed to the support of H. Russell, a Congregational minister and tem- abstinence during the last phase of the temperance perance activist. In 1895, this group combined movements. Urban areas were expanding, factory with a similar group in the District of Columbia, towns were a reality, and there was an increase in establishing a national society in 1896. By the the socializing at the end of the workday as well as end of the 1800s, the ASL, which represented a at the end of the workweek; consequently there was skillful political leadership resource for the Prohi- an increase in the production and consumption of bition movement, mobilized tremendous support alcoholic beverages. Several temperance societies for abstinence instead of just temperance. In that emerged during this period included the active 1896, the movement began to separate itself from participation of women and children—since wives a number of economic and social reforms, con- and children were often neglected or abused by centrating on the struggle of traditional rural drunken husbands and fathers. Irish-American Protestant society against developing urban sys- Catholics formed the Catholic Total Abstention tems and industrialization. Union in 1872; the WOMEN’S CHRISTIAN TEMPER- Part of the success of the ASL was its determina- ANCE UNION (WCTU) was formed in 1874; and the tion to remain a single-issue (prohibition) pressure Anti-Saloon League (ASL) emerged in 1896. These group that cut across all political party lines; the societies were able to mobilize tremendous support ASL also maintained a strong relationship with the for abstinence, rather than mere moderation in the Protestant clergy. It always put its own issue first intake of alcoholic beverages. At this time, the ide- but worked peacefully with the major political par- ology of the temperance movements centered upon ties and especially with legislators (Blocker, 1989). the evil effects of all alcohol, espousing the view By 1912, local prohibition laws had been passed to that alcohol had become the central problem in render most of the South legally dry. American life and that abstinence was the only In 1917, a major event boosted the cause of solution for this problem. national prohibition. The United States entered The WCTU was founded in Cleveland in 1874 into World War I, which prompted the ASL to push and emerged as the first mainstream organization for the suspension of the industrial distilling of in which women and children were systematically alcohol (ethanol). Very shortly after the U.S. entry involved in the temperance movement. Annie Wit- into the war, the selling of liquor near military tenmeyer, Frances Willard, and Carrie Nation pro- bases and to servicemen in uniform was prohibited vided this temperance-reform movement with cre- (Blocker, 1989). By 1918, the Eighteenth Amend- ative and dynamic leadership. The WCTU—a ment to the U.S. Constitution had been proposed crusade to shut down saloons and promote moral- and the ASL had pushed prohibition through 33 ity—took a radical stance, criticizing American in- state legislatures. Consequently, the Volstead stitutions by aligning itself with the feminist move- Act—called Prohibition—was ratified on January ment, the Populist party, and Christian Socialism. 16, 1919. It went into effect one year later, on Gusfield (1986) argues that, although, under the January 16, 1920, prohibiting the manufacture, leadership of Frances Willard (1879–1898), the sale, or transportation of alcoholic beverages. 1080 TEMPOSIL

CONCLUSION BIBLIOGRAPHY

Where the temperance movement was a middle- BLOCKER, J. S., JR. (1989). American temperance move- class reform movement, because it articulated the ments: Cycles of reform. Boston: Twayne Publishers. theme of self-control that was central to the mid- BLUMBERG, L. U., WITH PITTMAN, W. L. (1991). Beware dle-class ideology of the nineteenth century, some the first drink! The Washingtonian temperance move- members of the working class also supported re- ment and Alcoholics Anonymous. Seattle, WA: Glenn Abbey Books. form (Blocker, 1989). An ideology of ABSTINENCE became a rallying point for middle-class people BORDIN, R. (1981). Women and temperance: The quest for power and liberty, 1873–1900. Philadelphia: who saw the rich as greedy, the working class as Temple University Press. increasingly restless, and the poor as uneducated CLARK, N. (1976). Deliver us from evil. NewYork: Nor- immigrants. Thus, they felt the need to restore a ton. Dictionary of American temperance biography. coherent moral order, especially after the upheaval (1984). Westport, CT: Greenwood Press. of the Civil War and the ensuing period of indus- EPSTEIN, B. (1981). The politics of domesticity: Women, trial greed. At this time, the United States was evangelism and temperance in nineteenth-century undergoing economic expansion and deepening di- America. Middletown, CT. Wesleyan University Press. vision along class lines. Other reform groups, such GUSFIELD, J. R. (1986). Symbolic crusade: Status politics as the Progressive political party, joined the prohi- and the American temperance movement, 2nd ed. bitionists in their commitment to rid cities of Urbana, IL: University of Illinois Press. saloons so that the United States could move HOFSTADER, R. (1955). The age of reform. NewYork: toward becoming a virtuous and moral republic. At Vintage. the end of the nineteenth century, Americans LENDER, M., & HOUSTON, J. K. (1982). Drinking in seemed to be more receptive to moral than scientific America: A history. NewYork: Free Press. LEVINE, H. (1978). The discovery of addiction: Changing arguments for temperance reform and abstinence conceptions of habitual drunkenness in America. from alcohol. Journal of Studies on Alcohol, 39, 143–174. Members of the temperance movements were RORABAUGH, W. (1979). The alcoholic republic: An concerned not only with changing the behavior of American tradition. NewYork: Oxford University other social classes and groups but also about Press. changing themselves (Levine, 1978). They were TYRELL, I. R. (1979). Sobering up: From temperance to concerned that the pernicious effects of alcohol prohibition in antebellum America, 1800–1860. were also destroying the lives of Protestant middle- Westport, CT: Greenwood Press. class people. While some of these reform groups PHYLLIS A. LANGTON were not complete supporters of an abstinence ideology, they were concerned with rebuilding a national community and promoting the common wel- TEMPOSIL See Calcium Carbimide fare. Abstinence became the governing ideology of the many diverse groups that had mobilized to TERRORISM AND DRUGS The term promote a newsocial order. narcoterrorism has entered the popular lexicon as a As more scholars turn their attention to the shorthand to refer to the complex relationship be- study of the temperance era and the various tem- tween the illicit drug trade and terrorism. The perance movements and societies, additional term, however, has often been used interchange- knowledge and interpretations will continue to be ably to refer to two distinct aspects of this issue. published. The bibliography that follows provides examples of some newinterpretations of this EXPLOITING THE DRUG TRADE period. Narcoterrorism refers, first, to the activities of a number of guerrilla groups worldwide. These (SEE ALSO: Alcohol; Prohibition: Pro and Con; groups engage in terrorism and insurgency and also Treatment) exploit the drug trade for financial gain. In most TERRORISM AND DRUGS 1081 cases this exploitation involves rural-based guerril- USING THE TACTICS OF TERROR las. Guerrillas and the drug trade (especially culti- The second aspect covered under the rubric of vation and processing) both tend to thrive in rug- narcoterrorism has been the drug traffickers’ use of ged, remote areas where government control is the tactics of political terrorism—such as the car weak and where a nationally integrated economic bomb, kidnapping, and selective assassination—to infrastructure is lacking. undermine the resolve of various governments at Rural-based guerrillas make money primarily the highest levels to fight the drug trade. by extorting ‘‘war taxes’’ from growers and traf- Traffickers usually use members of their own fickers. Thus the relationship between guerrillas, organization to carry out such attacks. Sometimes, on the one hand, and the growers and the traf- however, traffickers have subcontracted to guerril- fickers, on the other, is frequently rooted in co- las. In late 1990, Colombia’s Pablo Escobar used ercion and conflict. the ELN to help conduct kidnappings to pressure Nevertheless, guerrillas, growers, and traffickers the Colombian government into negotiating with sometimes cooperate in a marriage of convenience. him. The degree of government pressure exerted in an Colombia has been hardest hit by the traffickers’ area can at times act as a unifying factor. Local use of terrorist tactics. Escobar’s Medellıń traf- family and/or personal relationships in a drug re- ficking group was responsible for a string of vicious gion can bring guerrillas, growers, and traffickers attacks in the 1980s and early 1990s. Among the together, at least for periods of time. victims and targets were a justice minister, an at- A number of guerrilla groups have used both torney general, Supreme Court justices, the editor coercion and cooperation to exploit the drug trade. of a leading newspaper, several presidential candi- Examples include the following: The Revolutionary dates, a commercial airliner, and the headquarters Armed Forces of Colombia (FARC), the country’s of Colombia’s equivalent of the FBI. largest and oldest insurgent group, and Colombia’s Escobar scored a major victory by using National Liberation Army (ELN); Peru’s Sendero narcoterrorism along with bribery to ensure the Luminoso (Shining Path) and the Revolutionary banning of extradition between Colombia and the Movement Tupac Amaru (MRTA); and the Kurdish United States in 1991. With the aid of corrupt Workers’ Party (PKK) in the Middle East. officials, Escobar escaped from a jail in 1992 and In addition to or apart from ‘‘taxation’’ and continued to carry out sporadic attacks until he was ‘‘protection’’ arrangements, various groups them- killed by Colombian authorities in December 1993. selves have been directly involved in the drug trade: Escobar’s death, however, did not end the rela- In COLOMBIA, the FARC controls its own coca tionship between terrorist groups and drug traf- fields and processing laboratories for COCAINE. fickers. During the 1990s, Peru and Bolivia suc- FARC may have some drug distribution networks, cessfully reduced the amount of coca production, although evidence for this is fragmentary. but this led to a dramatic rise in production in rural In Southeast Asia’s GOLDEN TRIANGLE of Thai- Colombia. Guerrilla and paramilitary groups con- land, Burma, and Laos, guerrillas have long been trol the major drug-producing regions, mostly in actively involved in every stage of the OPIUM/HER- southern Colombia. Drug money enables these OIN pipeline. They have frequently devolved into groups to purchase sophisticated weapons on the warlord trafficking organizations and dominate the black market that are used against government drug business in the area. forces. The situation in Columbia continued to de- Some guerrillas in the South Asian subcontinent teriorate in the late 1990s, to the point that the U.S. (the Indian peninsula of Bangladesh, Bhutan, Ne- government gave Colombia $1.3 billion in emer- pal, Pakistan, Sikkim, and India), such as the gency aid in 2000 to help fight the narcoterrorists. Tamil Tigers (LTTE) and the Sikhs, have used However, it remains to be seen whether this fund- expatriate communities abroad to smuggle heroin. ing and additional military aid will turn the tide Lebanon’s Hizballah reportedly smuggles drugs against narcoterrorism. as a result of a fatwah (an Islamic religious decree). Mexico also sawan upsurge of terrorist acts in In 1987, the police uncovered narcotics in a the 1990s. However, these acts were committed by Hizballah terrorist arms cache near Paris, France. drug traffickers and were not the product of revolu- 1082 TERRY & PELLENS STUDY tionary groups. The assassination of political can- TERRY & PELLENS STUDY In a time didates and government officials demonstrated the when the use of many drugs is illegal in the United vulnerability of the government to terrorist acts. States and the public is inundated with information For example, in February 2000, the police chief of on such drug use, it is probably surprising that this Tijuana, Alfredo de la Torre, was assassinated as he set of circumstances is a historically recent phe- drove to his office without bodyguards. The assassi- nomenon. Throughout most of the history of the nation came two days after the government an- United States, the manufacture, possession, and nounced a newattack on drug trafficking in the use of most drugs nowconsidered addictive were state of Baja California, where Tijuana is located. legal, and very little was known about these drugs, Italy too has suffered from drug violence. During their use or abuse. the 1980s and early 1990s, the Sicilian Mafia Other than ALCOHOL (through the TEMPERANCE retaliated for government crackdowns by killing a MOVEMENT), the drug that first captured the atten- number of the country’s leading prosecutors and tion of policymakers and medical and public- lawenforcement officers—often withcar bombs, in health sciences was OPIUM. An interest in the addic- spectacular fashion. tion to opiates in the United States can be found as far back as 1877, when Dr. Marshall conducted a IMPLICATIONS study of the number of opiate addicts in Michigan. However, this and the handful of similar efforts at Narcoterrorism in both its incarnations chal- epidemiological research conducted through 1920 lenges government efforts to control political vio- were plagued with methodological problems. Gen- lence, organized crime, and the drug trade. erally these studies were conducted by sending Although involvement in the drug trade may short questionnaires to physicians or pharmacists sometimes decrease the revolutionary fervor of a who, at that time, legally supplied people with guerrila group, the ability to derive income from this OPIUM and opium-based products. These physi- lucrative source strengthens the resources and capa- cians or druggists were simply asked to report the bilities of the groups to oppose the central govern- number of opium addicts they sawin their commu- ment either as subversives or as a criminal element. nities. All these studies were done in only one city, Whether or not the guerrillas obtain the funding county, or state—with one exception. The excep- through coercion or cooperation with growers and tion was a study done by the U.S. Department of traffickers, the result is usually a more formidable the Treasury, in an attempt to provide direct esti- foe. Most observers, for example, believe that ex- mates of the number of opium-addicted people in ploitation of the drug trade is the chief source of the nation. Unfortunately, none of these studies funding for Peru’s Sendero Luminoso. In general, would come close to meeting the requirements of the presence of guerrillas with an economic stake in sampling or of measures taken that would be re- the survival of the drug trade makes coun- quired today. ternarcotics efforts an even more risky undertaking. A very important step forward in the study of The willingness and ability of drug barons in drug addiction or dependency in general, and opi- some countries to use the tactics of terrorism adds a ate addiction in particular, took place in a now dangerous dimension to the threat posed by the drug classic study done for the Committee on Drug Ad- trade. In Colombia, narcoterrorism has pushed the dictions of the Bureau of Social Hygiene, in cooper- country to the brink of civil war and threatens to ation with the U.S. Public Health Service, by move the conflict into neighboring countries. In Charles E. Terry and Mildred Pellens from 1923 to other countries, such as Mexico and some of the 1924 (Terry & Pellens, 1924, 1927, 1928). This newly independent states of the former Soviet study was groundbreaking in several ways. First, Union, there is growing concern about the volatile rather than sending questionnaires to physicians mix of drugs, violence, and organized crime. and pharmacists, only about 30 percent of whom had responded in any of the previous studies, Terry (SEE ALSO: Crop-Control Policies; International and Pellens used field study techniques—their staff Drug Supply Systems) went to the sites of data collection. Second, rather MARK S. STEINITZ than relying on self-reports, Terry and Pellens took REVISED BY FREDERICK K. GRITTNER advantage of official records that physicians, den- TETRAHYDROCANNABINOL (THC) 1083

tists, veterinarians, institutions, and laboratories found in the HEMP plant, CANNABIS SATIVA, that were required to keep for all opium distribution, as causes the PSYCHOACTIVE effects in MARIJUANA, mandated by the HARRISON NARCOTIC ACT of 1914. BHANG,HASHISH, and GANJA. Hashish is derived Third, and perhaps most important, Terry and from the resin that oozes from the flowering tips of Pellens conducted their study in six sites across the the female plant; bhang comes from the dried United States: Sioux City, Iowa; Montgomery, Ala- leaves and flowering shoots of the female plant; and bama; Tacoma, Washington; Gary, Indiana; El- ganja comes from small leaves. THC is one of the mira, NewYork; and El Paso, Texas. Although no three natural cannabinoids—chemical constituents known precedent existed for such a research strat- of Cannabis—the other two being cannabinol egy, they selected these six cities on the basis of (CBN) and cannabidiol (CBD). racial characteristics, occupations, geographic re- As of 2000, marijuana is the most commonly gion, and other social demographic factors, so that used nonlegal drug in the United States. Its usage in aggregate these six sites could represent the peaked during the late 1970s, when about 60 per- United States as a whole. cent of high school seniors reported having tried As a consequence of these efforts, Terry and marijuana, with 11 percent reporting daily use. Us- Pellens not only attempted to collect data more age has declined since 1979; as of 1999, 2 to 3 accurately but also produced the first study of the percent of the 70 million Americans who had tried EPIDEMIOLOGY of drug addiction or dependence cannabis described themselves as daily users. that tried to take into account social and demographic factors that, nowas then, affect the num- PHARMACOLOGICAL EFFECTS ber and distribution of people who are addicted to For more than 30 years, the discovery of the or dependent upon chemical substances. Their mechanism of THC’s action had eluded the best book, The Opium Problem, which contains chap- researchers. The problem seems finally to have ters on the history of the problem, theories of its been resolved by the detection of specific can- etiology, and contemporary treatments, is consid- nabinoid-binding sites (RECEPTORS) in the brain. A ered a classic in the field. further step in unraveling the mechanism of THC’s action has been the cloning of the cannabinoid (SEE ALSO: Epidemiology of Drug Abuse; High receptor. School Senior Survey; National Household Survey The pharmacological effects of THC vary with on Drug Abuse; Treatment) the dose, the method of administration, the user’s degree of experience with THC, the setting, and the BIBLIOGRAPHY user’s vulnerability to the psychoactive effects of the drug. Most users seek to experience a ‘‘high,’’ or TERRY, C. E., & PELLENS, M. (1928). The opium problem. NewYork: Bureau of Social Hygiene. ‘‘mellowing out.’’ The high begins about 10 to 20 minutes after smoking and lasts about 2 hours. The TERRY, C. E., & PELLENS, M. (1927). A further study and report on the use of narcotics under the provisions of psychological effects obtained during the high are federal law in six communities in the United States of often related to the setting in which the drug is America, for the period July 1st, 1923 to June 30th, taken. 1924. NewYork: Bureau of Social Hygiene. Inhalation. THC is most commonly taken into the body by inhaling the smoke from marijuana TERRY, C. E., & PELLENS, M. (1924). Preliminary report ‘‘joints.’’ A joint of good quality contains about 500 on studies of the use of narcotics under the provisions milligrams of marijuana, which in turn contains of federal law in six communities in the United States between 5 and 15 milligrams of THC. Blood levels of America, for the period July 1st, 1923 to June 30th, of THC rise almost as rapidly after inhaling smoke 1924. NewYork: Bureau of Social Hygiene. as they do after intravenous administration of ERIC O. JOHNSON THC. That the drug should be so rapidly absorbed is an indication of the efficiency of the lung as a trap for the drug. THC is quickly redistributed into TETRAHYDROCANNABINOL (THC) other tissues so that blood levels decline over the Tetrahydrocannabinol, or THC, is a chemical course of 3 hours to negligible amounts. The usual 1084 TETRAHYDROCANNABINOL (THC) symptoms of marijuana intoxication are almost The physical effects of THC include dry mouth, completely gone by that time. abnormalities in heart rhythm, and abnormal Ingestion. THC is absorbed slowly and unreli- precancerous changes in the tissues that line the ably from the gut after oral administration. Blood airway and the lungs. People who are heavy users levels of the drug peak between 1 and 2 hours after of marijuana often develop bronchitis and lar- ingestion. These peak concentrations are also con- yngitis. As of 1999, however, it was not definitely siderably lower than those following smoking. known whether persons who smoke only marijuana THC is easily soluble in fats. It is taken up and have an increased risk of lung cancer, as compared stored in the fatty tissues of the body and in the to those who smoke tobacco. THC lowers the sperm gray matter of the brain. This pattern of storage is count in males and may produce abnormal men- one reason why THC remains so long in the body. strual cycles in females. Women who are pregnant Withdrawal. THC does not produce a severe or nursing are advised to avoid marijuana, as THC withdrawal syndrome. Heavy users, however, fre- is secreted in human breast milk. quently report insomnia, nervousness, mild stomach upset, and achy muscles— particularly if they MEDICAL USES OF THC stop their use suddenly. THC has been used in medicine to treat the nausea that many cancer patients experience after DRUG TESTING AND chemotherapy. It has also been used to prevent FORENSIC ISSUES convulsions and to lower the fluid pressure inside Drug testing is an issue with respect to mari- the eye in treating glaucoma. juana because of the effects of THC on coordina- In recent years, THC has been replaced in medi- tion, sense of timing, and impairment of depth cal use by a synthetic derivative called dronabinol perception as well as short-term memory. It is haz- (Marinol). Dronabinol is used as an antinausea ardous for someone who has taken a moderate dos- drug, an appetite stimulant in AIDS patients, and age of marijuana to drive or to operate heavy an antiglaucoma medication. equipment in the workplace. Urine testing, however, is hardly useful for de- (SEE ALSO: Drug Metabolism; Drug Testing and termining impairment, since the metabolic prod- Analysis; Pharmacokinetics) ucts of THC are detectable for as long as 50 days in chronic users. Urine tests are also of little use in BIBLIOGRAPHY determining the patient’s pattern of use. BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck manual of diagnosis and therapy, 17th ed. EFFECTS OF THC Whitehouse Station, NJ: Merck Research Laborato- THC produces a variety of complex sensations ries. and behavioral effects in humans. The effects on BROPHY, J. J. (1994). Psychiatric disorders. In L. M. memory, coordination, and sense of time have al- Tierney et al. (Eds.), Current medical diagnosis & ready been noted. Some studies indicate that THC treatment, 33rd ed. Norwalk, CT: Appleton & Lange. produces impairment of human cognitive functions HERKENHAM, M., ET AL. (1990). Cannabinoid receptor as well. In addition, many users experience in- localization in the brain. Proceedings of the National creased appetite. Psychological effects range from a Academy of Science, 87, 1932–1936. pleasant sense of mellowness to negative effects HOLLISTER, L. E., ET AL. (1981). Do plasma concentra- that include panic reactions, anxiety, hallucinations of delta-9-tetrahydrocannabinol reflect the de- tions, and schizophrenic symptoms. THC can also gree of intoxication? Journal of Clinical Pharmacol- cause relapses in schizophrenic patients, even those ogy, 21, 1715–1755. who are taking antipsychotic medications. These O’BRIEN, C. P. (1996). Drug addiction and drug abuse. negative effects are more common with high doses In J. G. Hardman et al. (Eds.), Goodman and of the drug and with oral ingestion rather than Gilman’s the pharmacological basis of therapeutics, smoking. 9th ed. NewYork: McGraw-Hill. TOBACCO: DEPENDENCE 1085

WILSON, B. A., SHANNON, M. T., & STANG, C. L. (Eds.) several times before they are successful. Both the (1995). Nurses drug guide, 3rd ed. Norwalk, CT: direct effects of nicotine on the body and behav- Appleton & Lange. ioral associations with those effects learned over the LEO E. HOLLISTER years of tobacco use keep people going back for REVISED BY REBECCA J. FREY more even when they want to quit. The role of nicotine in tobacco use is complex. Nicotine acts on the body directly to produce effects THC See Tetrahydrocannabinol such as pleasure, arousal, enhanced vigilance, relief of anxiety, reduced hunger, and body-weight reduction. It may also reverse the withdrawal who is THEOBROMINE This ALKALOID belongs to symptoms that occur in a nicotine-dependent per- the class of drugs called methylxanthines; it is simi- son trying to quit, when nicotine levels in the body lar to theophylline and to CAFFEINE. Theobromine fall. These symptoms include anxiety, irritability, (3,7-dimethylxanthine), however, is somewhat difficulty concentrating, restlessness, hunger, de- weaker than these two compounds and currently pression, sleep disturbance, and craving for to- has almost no practical use in medicine. bacco. When this happens, the use of nicotine Theobromine is found in the seeds of the plant Theobroma cacao, which is the well-known source (whether tobacco or nicotine-containing medications) usually makes people feel better by reversing of CHOCOLATE and cocoa. The cacao seeds have the unpleasant withdrawal symptoms. caffeine too (as does TEA, which contains small amounts of theobromine and theophylline); caf- Nicotine also acts indirectly, through a learning feine has powerful stimulant effects on the brain, process that occurs when the direct effects of nic- whereas theobromine has very little (although pop- otine occur repeatedly in the presence of certain ular articles alleged for years that theobromine features of the environment. As a result of the makes one feel ‘‘happy’’). High doses of theobro- learning process, called conditioning, formerly in- mine can, however, affect several physiological significant environmental factors become cues for functions in the body, such as increasing the forma- the direct actions of nicotine. These factors can tion of urine in the kidney. become either pleasurable in themselves or they can serve as a triggering mechanism for lighting up BIBLIOGRAPHY a cigarette. For example, the taste, smell, and feel of tobacco often evoke a neutral response and SERAFIN, W. E. (1996). Drugs used in the treatment of sometimes repugnance in a nonsmoker. After years asthma. In J. G. Hardman et al. (Eds.), The Pharma- of experiencing the direct effects of nicotine in the cological Basis of Therapeutics, 9th ed. (pp. 659– presence of tobacco, however, a smoker finds the 682). NewYork: McGraw-Hill. sensory aspects of tobacco pleasurable. MICHAEL J. KUHAR The indirect or conditioned effects of nicotine are responsible for much more complicated learning than the learning associated with nicotine’s di- THERAPEUTIC COMMUNITIES See rect effects. Conditioning is also the process Treatment Types: Theraputic Communities whereby the situations in which people often smoke such as after a meal, with a cup of coffee, with an TOBACCO: DEPENDENCE In the United alcoholic beverage, while doing a task at work, States as of 1999, there were about 57 million while talking on the phone, or with friends who also cigarette smokers-representing 25 percent of the smoke become in themselves powerful cues for the adult population. Another 5 percent (men) use urge to smoke. When people stop using tobacco, smokeless tobacco (chewing tobacco or snuff). therefore, the direct effects of nicotine are not the Most (70-80%) say they would like to quit. Unfor- only pleasures they must give up. They must also tunately, they are dependent on (addicted to) nic- learn to forgo the indirect effects of nicotine: those otine, an alkaloid that makes it difficult to stop experiences that, through learning, have become ei- using tobacco. Most of them will have to try to quit ther pleasurable in themselves or a cue to smoke. 1086 TOBACCO: DEPENDENCE

MOTIVATION FOR QUITTING sions when alcoholic beverages are consumed. Emotional upset and depression are also commonly Most Americans who use tobacco would like to reported cues for lighting up. quit, and the reasons for wanting to quit vary. The most common include (1) a concern for one’s health; (2) a concern for the health of one’s family MANAGING URGES TO SMOKE and friends (this may entail concern about the A smoker who contemplates quitting often harmful effects on children of secondhand smoke thinks that smoking cessation is a simple matter of or concern about setting a bad example for them); refraining from smoking during a period of nicotine (3) social pressure; (4) and economic factors (ciga- withdrawal. Urges to smoke are powerful, however, rettes are expensive). and occur long after the period of nicotine withdrawal has ended. Tobacco users must not only not STAGES OF QUITTING smoke but must, in fact, learn a new, tobacco-free lifestyle. Some learn on their own; others seek pro- Successful quitting of tobacco use usually occurs fessional help. Key aspects of learning a tobacco- as a process over time, a series of mental stages or free lifestyle include anticipating and managing steps that the smoker goes through in quitting: 1. withdrawal symptoms and environmental triggers Precontemplation. The person is smoking and is for smoking. The environment might be managed not motivated to stop smoking during this stage. 2. to minimize smoking triggers by, for example, Contemplation. The person is still using tobacco (1) sitting in nonsmoking sections of restaurants; and is motivated to quit but has not settled on a (2) removing ashtrays from one’s home and office; quit date that is within one month. 3. Action. The (3) leaving the table as soon as possible after meals person has a stop date and a plan that was either and engaging in other activities such as talking, already implemented or will be implemented walking, or doing the dishes; (4) avoiding (at least within one month. 4. Maintenance. The person has temporarily) situations that trigger smoking, such discontinued the regular, daily use of tobacco for a as drinking alcohol or coffee when smokers are minimum of one month. around and going to places, parties, or bars where people smoke; (5) actively seeking social support RELAPSE for smoking cessation. The encouragement of a Most tobacco users who try to quit agree with husband or wife, or of friends and others who have Mark Twain, who said, ‘‘To cease smoking is the quit or are in the process of quitting, also makes it easiest thing I ever did; I ought to knowbecause easier. Smokers who enjoy handling cigarettes or I’ve done it is a thousand times.’’ People who are having something in their mouths need to substi- addicted to tobacco and who try to quit are able to tute something for these smoking-related behav- do so for a brief period of time, but most resume iors. They may chewgum, toothpicks, sunflower smoking. For example, 66 percent of smokers who seeds, or something similar; munch food or low- try to quit on their own or with minimal outside calorie snacks; exercise to take up time they might help relapse within 2 days, 90 percent relapse otherwise spend smoking and to reduce any weight within 3 months, and 95 percent to 97 percent gain; snap, roll, or twist rubber bands on their relapse within 1 year of quitting. The key to suc- wrist. What people think about while quitting is an cessful smoking cessation is an understanding of important factor in relapse. They need to teach what triggers relapse, and what strategies are effec- themselves to maintain thoughts that may be useful tive in preventing relapse. Some of the most impor- in overcoming urges to smoke. Instead of thinking tant triggers for lighting up a cigarette are with- about the expected pleasures of a cigarette, the drawal symptoms, environmental cues acquired would-be quitter can substitute a stream of through learned associations, and emotional upset. thoughts about the risks of smoking, the benefits of Relapse is promoted by such common withdrawal not smoking, the commitment to not smoking, the symptoms as difficulty concentrating, irritability, pleasures of an anticipated reward for not smoking, and weight gain. Environmental cues to relapse in- or the day’s next activity. Stress management is clude the presence of other smokers such as a also important for successful quitting. Smokers spouse, friends, or coworkers who smoke and occa- soon recognize that giving up smoking is a substan- TOBACCO: DEPENDENCE 1087 tial stress in itself. They can resort to some strate- made up of small groups of quitting smokers who gies that may reduce stress, such as meditation, discuss their reasons for not smoking, their prob- relaxation, and physical exercises. Other aspects of lems with quitting, and how they manage these self-management during smoking cessation include problems. Participants in the programs can pick up setting realistic goals and some sensible rewards for practical skills in managing their smoking-cessa- behavior that leads to reducing tobacco use. Some tion attempts and also obtain social support for days a realistic goal is a short-term one and in- their efforts. The cessation programs are offered by volves just getting through each urge to smoke public-health organizations such as the American without succumbing. The smoker who is quitting Lung Association and the American Cancer Soci- can use any of the already mentioned substitution ety, and also by private companies such as or distraction strategies while remembering that Smokestoppers and Smokenders. urges to smoke are likely to continue to come and Physician- and Clinic-Assisted Quitting. go for some time. Rewarding oneself for meeting Many physicians’ offices and some hospital clinics even the short-term goals is important. Rewards for offer assistance in smoking cessation. The clinics not using tobacco can include newclothes, a new are particularly useful for people who have medical book, time to develop a newhobby, or anything else problems that need to be treated at the same time, the former smoker might enjoy. Many rewards can for people who have tried before and failed to quit, be paid for from money saved by not buying to- or for people who may benefit from taking nicotine- bacco. replacement medications. Smokers can turn to these health-care facilities for advice on howto quit and for self-help material as well as for support and INDEPENDENT QUITTING information during the different stages of quitting. Most smokers quit smoking without professional Pharmacotherapies for Tobacco Depen- help. People who quit on their own can benefit dence. Medications for tobacco dependence are by (1) clearly identifying the reasons they want to categorized as first-line or second-line depending quit (i.e., health, cost of cigarettes, etc.); on the level of evidence supporting their efficacy. (2) anticipating potential barriers to or problems First-line medications include the nicotine replace- with quitting and how to manage them; (3) setting ment systems, i.e., nicotine chewing gum, nicotine a firm quit date and on that date removing all patch, nicotine nasal spray, and nicotine inhaler, cigarettes and ashtrays from the home or office. In and bupropion. Second-line medications include addition, any friends or family members who nortriptyline and clonidine, and combination nic- smoke should be asked not to offer cigarettes. Per- otine replacement therapy. sistence in trying to quit almost always works. Nicotine replacement treatments. Recent research Smoking a cigarette in the course of trying to quit has shown that nicotine replacement increases by should not become the end of the smoking-cessa- about twofold the likelihood of a person success- tion effort. Most smokers try to quit several times fully quitting smoking. Nicotine-replacement ther- before they are successful. Many aids are available apy can reduce the severity of nicotine withdrawal. to tobacco users who quit on their own. Smoking- Some tobacco users are concerned about the haz- cessation program guides and motivational and ed- ards of taking in nicotine, but the hazards of nic- ucational tapes—audiotapes and videotapes—may otine-replacement therapy are much less than those be obtained from physicians, hospitals, or organi- associated with smoking. In the first place, the zations such as the American Lung Association, the amount of nicotine ingested in replacement ther- American Cancer Society, or the American Heart apies is less than that taken in from cigarettes. In Association, or they may be found in bookstores the second place, nicotine-replacement medica- and libraries. tions do not expose smokers to the other hazards of cigarette smoke which include carbon monoxide, tar, cyanide, and a number of other toxic sub- ASSISTED QUITTING stances. On balance, using the nicotine replacement Smoking-Cessation Programs. These pro- systems is much safer than smoking cigarettes. grams are available to help smokers in most com- The nicotine-replacement medications are par- munities. They usually involve attending meetings ticularly useful with more seriously addicted 1088 TOBACCO: DEPENDENCE smokers, but they are not a simple cure; rather, Geigy), Nicoderm (Marion-Merrell Dow), Nicotrol they must be used as part of a program of learning (McNeil), and Prostep (Lederle). All of these are to live a tobacco-free lifestyle. Currently, four nic- available as over-the-counter medications. The otine-replacement products are marketed in the patches deliver nicotine doses that are equivalent to United States: nicotine chewing gum (also called smoking fifteen to twenty cigarettes (one pack) per Nicorette), nicotine patches (also called day. Higher-dose patches are used during the ini- transdermal Nicotine Delivery Systems), nicotine tial three months of quitting, and lower-dose nasal spray, and nicotine inhaler. patches are available for subsequent tapering. Nicotine Chewing Gum. Nicotine chewing gum Smokers who want to quit are instructed to first contains nicotine (bound to a resin, a chemical stop smoking and then to apply the patch daily. substance that binds other chemicals) and sodium The usually minor side effects from nicotine bicarbonate. The sodium bicarbonate is necessary patches may include itching or burning over the for keeping the saliva at an alkaline (basic) pH, patch site, which usually subsides within an hour, which in turn is necessary for allowing nicotine to and local redness and mild swelling. Some people cross the lining of the mouth. The gum is available experience a sense of stimulation and, occasionally, in strengths of 2 and 4 milligrams (mg), although insomnia; with sleep may come vivid dreams. the dose actually delivered to the chewer is 1 mg These effects tend to occur during the first fewdays and 2 mg, respectively. Nicotine is absorbed from of patch use but not thereafter. the gum gradually over 20 to 30 minutes, in the Nicotine Nasal Spray. The nicotine nasal spray was course of which nicotine levels similar to those seen designed as a more rapid means of delivering nic- after smoking a cigarette are produced in the blood. otine to the smoker than the gum or the patch. The The gum is meant to be chewed intermittently, to nasal spray consists of a small bottle containing a allowtime for the nicotine in the saliva to be ab- 10-mg/ml nicotine solution. A 50-milliliter spray sorbed. One should not chewthe gum whiledrink- containing 0.5 mg nicotine can be conveniently de- ing coffee, fruit juice, or cola drinks, because these livered using an accompanying manual pump. beverages, by making the mouth more acidic, re- Each dose consists of two squirts, one to each nos- duce the absorption of nicotine from the gum. tril. This mechanism can deliver nicotine to the Smokers are instructed to quit smoking and then to brain within 10 minutes, providing the most rapid chewthe gum regularly throughout the day, and nicotine delivery among the currently available nic- also whenever they have the urge to smoke a ciga- otine replacement delivery systems. Patients are rette. For maximum efficacy, nicotine gum should advised to use one or two doses per hour and may not be chewed within 10 minutes of drinking any increase as needed. The minimum treatment is 8 beverage. Most people need to chew8 to 10 pieces doses per day, with a maximum limit of 40 doses per day to obtain optimal benefits. Usually they per day (5 doses per hour). The side effects associ- chewthe gum for 3 to 6 months but need to chew ated with the nasal spray are nasal irritation and fewer pieces during the last couple of months. Side throat irritation, sneezing, coughing, and teary effects from chewing nicotine gum may include eyes. These symptoms often occur during the first fatigue and soreness of the jaw, loosening of dental week of use but typically decline with continued fillings, and occasionally nausea, indigestion, gas, use. or hiccups, particularly if one has chewed the gum Nicotine Inhaler. The nicotine inhaler consists of a so rapidly as to swallow nicotine-rich saliva. plastic tube-like mouthpiece into which is placed a Nicotine Patches. To make it easier to stop smok- cartridge containing a nicotine-impregnated plug. ing, researchers developed patches that administer Nicotine vapor is produced when warm inhaled air nicotine without the side effects of nicotine chewing passes through the plug and nicotine is delivered gum. Patches deliver nicotine in its un-ionized (un- through the buccal mucosa. The inhaler produces a charged) chemical form, thereby allowing the drug rate of nicotine delivery similar to the nicotine gum. to pass through the skin readily. Various patches Dose is related to temperature, consequently, low deliver different doses and are applied to the skin temperatures will inhibit the release of nicotine. once a day, for times that range from sixteen to Clinical trials of the nicotine inhaler have shown twenty-four hours. Four patches were available as that it produces double quit rates compared with of 1994 in the United States: Habitrol (Ciba- placebo, similar to the effects observed with the TOBACCO: DEPENDENCE 1089 three other nicotine replacement systems. Side ef- tobacco dependence. Increased abstinence rates fects from the inhaler include mild mouth and with notriptyline use, compared with placebo, were throat irritation, coughing, and runny nose. The observed in two controlled trials. In those smoking frequency and severity of these symptoms decline cessation trials, nortriptyline use was initiated at a with continued use of the inhaler. dose of 25 mg/day, and increased gradually to 75 Bupropion. Bupropion sustained release (SR) is a to 100 mg per day over 12 weeks. Sedation, dry non-nicotine medication that ranks as a first-line mouth, blurred vision, urinary retention, form of treatment. It is available by prescription lightheadedness, and shaky hands are the most only. Bupropion was originally marketed as an an- commonly reported side effects of nortriptyline use. tidepressant, Wellbutrin. On the strength of evi- Nortriptyline may also cause cardiovascular dence from several placebo-controlled trials, the changes. This side effect profile and the need for FDA approved the marketing of bupropion (SR), evidence from more controlled studies consigns under the trade name Zyban, as a treatment aid for nortriptyline to the status of a second-line smoking smoking cessation. The mechanism by which cessation aid at the present time. bupropion assists smokers is not clear but it is Other treatments. A number of other treatments thought to be related to both noradrenergic and are available or have been used in the past to aid in dopaminergic activity. Patients are advised to be- smoking cessation. Although the effectiveness of gin using bupropion with a dose of 150 mg per day these treatments has not been established by medi- for three days, then to increase to 150 mg twice a cal research, some individuals may benefit from day for one to two weeks prior to a selected day, them. None of these treatments, however, can mag- with continued treatment for up to seven to twelve ically cure smokers of their tobacco addiction with- weeks following the quit date. Bupropion has been out the commitment and effort that are usually shown to reduce withdrawal symptoms and to re- required to quit. duce the weight gain usually associated with Hypnosis has been widely used to increase a stopping smoking. The most common side effects smoker’s motivation or commitment to stop. While reported by bupropion users have been insomnia under hypnosis, the smoker receives suggestions, and dry mouth. Bupropion is contraindicated in such as ‘‘smoking is a poison to your body,’’ ‘‘you persons with a history of seizures, or of eating need your body to live,’’ ‘‘you owe your body re- disorders, and those who have used a monoamine spect and protection.’’ This treatment probably oxidase inhibitor in the past 14 days. works best in combination with the previously dis- Clonidine. Clonidine is an alpha2-noradrenergic cussed behavioral modification programs. agonist that was initially used for the treatment of Acupuncture as a smoking-cessation technique hypertension, and subsequently found to diminish involves the placement of needles or staples in vari- symptoms of both opiate and alcohol withdrawal. ous parts of the body, most commonly the ears. The efficacy of clonidine as a short-term smoking Although acupuncture may be helpful for some cessation aid was demonstrated in several studies in smokers, a meta-analysis did not support the effi- which clonidine was delivered either orally or in cacy of this form of treatment. patch form. This drug has not received FDA ap- Lobeline and silver acetate medications have proval as a smoking cessation aid, however, and been available in pharmacies without a physician’s should be considered a second-line treatment when prescription. Lobeline, a chemical similar to nic- first-line pharmacotherapies have not been suc- otine but with less psychoactivity, has been recently cessful. Clonidine use is associated with reductions removed from the market by the Food and Drug in pulse rate and blood pressure, and abrupt dis- Administration. Lobeline has been available in pre- continuation could result in a rapid rise in blood scriptions such as CigArrest, Bantron, and pressure and catecholamine levels. Side effects re- Nikoban. Silver acetate, available in a chewing ported with clonidine use include dry mouth, gum, mouthwash, mouth spray and lozenges, acts drowsiness, dizziness, and sedation. Appropriate as a deterrent. Tobacco smoke combines with the dose levels have not been established. silver in the mouth to precipitate silver sulfide, Nortriptyline. Nortriptyline is used primarily as an which has an unpleasant taste. The unpleasant antidepressant (Pamelor) and has not been evalu- taste presumably decreases the incidence of smok- ated or approved by the FDA for the treatment of ing. 1090 TOBACCO: HISTORY OF

TREATMENT OF SMOKELESS TOBACCO ADDICTION Much evidence indicates that the use of smokeless tobacco produces addiction and leads to serious health consequences as does the use of smoked tobacco. However, little is known about effective treatment for smokeless tobacco (i.e., snuff or chewing tobacco) addiction. The general behavioral approach is similar to that for cigarette smoking, although the specific learned associations and cues are naturally somewhat different. Self- help materials are available from a variety of sources in the United States. Some strategies include the use of alternative activities, such as chewing gum, hard candy, sunflower seeds, nuts, toothpicks, or beef jerky. Formal treatment programs are also available in some parts of the country. At the present time, insufficient evidence exists to suggest that the use of established medications designed for helping cigarette smokers increases long- Three hundred tobacco farmhands pose during term cessation among users of smokeless tobacco. picking season in Granby, Connecticut, circa 1903. ( CORBIS) (SEE ALSO: Addiction: Concepts and Definitions; Relapse Prevention; Tobacco Smoking Cessation and Weight Gain; Treatment) Nicotiana tabacum is, however, the major BIBLIOGRAPHY source of commercial tobacco, although it has been hybridized with other Nicotiana species, with re- UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SER- sultant alteration in chemical composition. VICES. (2000). Treating tobacco use and dependence. Nicotiana tabacum is a broad-leaf plant that grows Clinical Practice Guidelines. Chapter 6. Evidence, from 3 to 10 feet (1–3 m) tall and produces 10 to 49-89. 20 leaves radiating from a central stalk. Nicotiana NEAL L. BENOWITZ rustica, also known as Indian tobacco, was first ALICE B. FREDERICKS cultivated by Native Americans and was probably REVISED BY LIRIO S. COVEY the tobacco offered to Columbus. The word tobacco comes into English (c. 1565) from the Span- ish word tabaco, probably from the Taino word for TOBACCO: HISTORY OF Tobacco the roll of leaves containing the N. rustica that the generally refers to the leaves and other parts of American natives of the Antilles smoked. certain South American plants that were domesti- cated and used by Native Americans for the alka- HISTORY OF TOBACCO USE loid NICOTINE. Tobacco plants are a species of the genus Nicotiana, belonging to the Solanaceae Tobacco was introduced to Europeans by Native (nightshade) family; this also includes potatoes, to- Americans at the time of Columbus’s exploration of matoes, eggplants, belladonna, and petunias. In- the NewWorld (1492–1506). The first writtenrec- cluding plants used for tobacco, there are sixty-four ords of tobacco use date from this time, but there is Nicotiana species. The two widely cultivated for archaeological evidence for tobacco’s wide use in use as tobacco are Nicotiana tabacum and the Americas as early as C.E. 600–900. Native Nicotiana rustica, the latter of which contains the Americans considered tobacco as sacred, a plant higher levels of nicotine. used in social, fertility, and spiritual ritual. For TOBACCO: HISTORY OF 1091 example, tobacco was used for seasonal ceremo- Despite James’s opposition, however, tobacco use nies, for sealing friendships, preparing for war, flourished. Eventually, even James lessened his op- predicting good weather or good fishing, planting, position to tobacco because of the lucrative income courting, consulting spirits, and preparing magical from its taxation. cures. The desired effects of tobacco were a trance During the 1600s, tobacco use had spread state, achieved by using the leaves in various ways, throughout Europe, Russia, China, Japan, and the including smoking, chewing, snuffing, drinking west coast of Africa. Over the centuries, draconian (tobacco juice or tea), licking, and administering penalties for tobacco use were occasionally promul- enemas. gated. For example, Murad the Cruel of Turkey Acute nicotine poisoning was a central aspect of (1623–1640) ordered that tobacco users be the practice of shamanism in many parts of South beheaded, quartered, and/or hanged. Nevertheless, America. South American shamans would smoke or smoking persisted. In the American colonies, to- ingest tobacco to the point of producing a nicotine- bacco became the most important export crop and mediated trance or coma. The dose of nicotine was instrumental in the economic survival of the could be titrated to produce a coma state resem- colonies. bling death, but from which the shaman would By the nineteenth century, tobacco production recover. Recovery from apparent death enhanced was a mainstay of American capitalism. Most to- the perception of the shaman’s magical powers. bacco was smoked as cigars or in pipes, or used as In 1492 Columbus encountered natives in His- snuff. Cigarettes were hand rolled. A skillful paniola smoking tobacco in the form of large cig- worker could roll four cigarettes per minute. Ciga- ars. Enticed by the sacred and special regard in rette smokers were primarily boys or women, and which they held tobacco, Columbus’s crew experi- smoking was a behavior confined to the lower so- mented with tobacco smoking and soon became cioeconomic class. The invention of the cigarette enthusiasts. Tobacco was brought back to Europe rolling machine by James Bonsack in 1881 made and, within a few decades, its use spread. People tobacco use inexpensive and convenient. Bonsack smoked it in the form of cigars and pipe and used it went into business with W. B. Duke and Sons in as snuff or chewing tobacco. Within forty years of Durham, North Carolina. Together they improved Columbus’s arrival, Spaniards were cultivating to- the machine; by April 30, 1884, the device could bacco in the West Indies. Tobacco use then became roll 120,000 cigarettes per day. widespread in Europe and in Spain and Portugal’s Just as cigarettes were becoming widely avail- American colonies by the late 1500s. able and affordable, tobacco manufacturers In 1570 the tobacco plant had been named strongly promoted their use. Massive advertising nicotiana after Jean Nicot, the French ambassador campaigns, government issue of cigarettes to sol- to Portugal who introduced tobacco to France for diers during the world wars, glamorization of ciga- medicinal use. Tobacco was said to be useful in the rettes in motion pictures, and the gradual incorpo- prevention of plague and as a cure for headache, ration of women into the smoking market increased asthma, gout, ulcers, scabies, labor pains, and even the popularity of cigarette smoking in the United cancer. In the late 1500s, Sir Walter Raleigh pop- States and around the world. Smoking rates peaked ularized the smoking of tobacco for ‘‘pleasure’’ in in the United States for men in 1955, with 50 the court of Queen Elizabeth (reigned 1558– percent of men smoking, and in 1966 for women, 1603); from there it spread to other parts of En- with 32 percent of women smoking. As a result of gland. clever marketing by the cigarette companies, smok- James I of England (reigned 1603–1625), who ing at that time was considered to be sophisticated, succeeded Queen Elizabeth, was strongly opposed glamorous, individualistic, and even healthful. to tobacco use and wrote the first major antitobacco While there had been occasional reports on the treatise, entitled ‘‘Counterblast to Tobacco,’’ in health hazards of cigarette smoking from the time 1604. King James described tobacco as ‘‘a custome of King James, the first large-scale studies docu- loathsome to the eye, hateful to the nose, harmful to menting the link between cigarette smoking and the brain, dangerous to the lungs, and in the black cancer appeared in 1952 (Doll & Hill) and 1956 stinking fume thereof nearest resembling the hor- (Wynder et al.). Subsequently, hundreds of studies rible stygian smoke of the pit that is bottomless.’’ have shown that cigarette smoking accounts for 30 1092 TOBACCO: INDUSTRY percent of cancers—including some cancers of the 2. Surgeon General’s Warning: Quitting Smoking lung, mouth, throat, esophagus, bladder, and kid- NowGreatly Reduces Serious Risks to Your ney, as well as some leukemia; and that it is the Health cause of some heart and vascular disease, stroke, 3. Surgeon General’s Warning: Smoking by Preg- emphysema, chronic obstructive lung disease, and nant Women May Result in Fetal Injury, Prema- other health problems. In 1962 the Royal College of ture Birth, and LowBirth-Weight Physicians in the United Kingdom, and in 1964 the 4. Surgeon General’s Warning: Cigarette Smoke U.S. surgeon general, issued reports on smoking Contains Carbon Monoxide. and health, indicating that cigarette smoking most The three smokeless tobacco warnings that are probably caused some lung cancers and other rotated are these: health problems. These reports mark the beginning 1. Warning: This Product May Cause Mouth of modern public-health efforts to control tobacco Cancer use. 2. Warning: This Product May Cause Gum Disease Subsequent landmarks in tobacco control in the and Tooth Loss U.S. include the following: 3. Warning: This Product Is Not a Safe Alternative ● 1965—Federal Cigarette Labeling and Ad- to Cigarettes vertising Act (PL89-92) required health As a consequence of education and other public warnings on cigarette packages and an annual health activities, tobacco use has declined in the report to Congress on the health consequences United States. In the late 1900s, 25 percent of of smoking. Americans, about 43 million people, smoke. About ● 1969—Public Health Cigarette Smoking Act 45 million former smokers have quit. Unfortu- (PL91-222) strengthened health warnings on nately, adult smoking rates have been declining cigarette packs and prohibited cigarette ad- very slowly in recent years because adolescents are vertising on television and radio. taking up smoking at undiminishing rates and ● 1973—Little Cigar Act (PL93-109) extended growup to become addicted adult smokers. the broadcast ban on cigarette advertising to little cigars. (SEE ALSO: Advertising and Tobacco Use; Nicotine ● 1984—Comprehensive Smoking Education Delivery Systems for Smoking Cessation) Act (PL98-474) required rotation of four spe- NEIL L. BENOWITZ cific health warnings and mandated that the ALICE B. FREDERICKS cigarette industry provide a list of cigarette REVISED BY ANDREW J. HOMBURG additives. ● 1986—Comprehensive Smokeless Tobacco Health Education Act (PL99-252) required TOBACCO: INDUSTRY The tobacco in- three rotating health warnings on SMOKELESS dustry is made up of the complex of primary sup- TOBACCO packages and advertisements, a list pliers, manufacturers, distributors (both wholesale of additives and nicotine content in smokeless and retail), advertising agencies, and media outlets tobacco products, prohibited smokeless to- that produce, promote, and sell tobacco products, bacco advertising on television and radio, and as well as the law, public relations, and lobbying mandated reports to Congress on smokeless firms that work to protect these products from tobacco and a public information campaign on stringent public-health regulation and control. In due time, however, these precautions failed. The the health hazards of smokeless tobacco. industry evolved in the late nineteenth and early The four warnings currently rotated among cig- twentieth century from many, relatively small en- arette packs are the following: terprises that produced tobacco products for puffing, snuffing, and chewing. The products of 1. Surgeon General’s Warning: Smoking Causes these small firms delivered nicotine to the nasal and Lung Cancer, Heart Disease, Emphysema, and oral mucosa. With the evolution and refinement of May Complicate Pregnancy the cigarette, the industry developed first into a TOBACCO: INDUSTRY 1093 monopoly and then into an oligopoly in which a FROM COTTAGE INDUSTRY TO handful of major producers made this more sophis- MONOPOLY TO OLIGOPOLY ticated nicotine delivery system: a device that de- Relatively expensive, hand-rolled cigarettes be- livers nicotine by inhalation to the lungs and thence came popular novelties in the United States and rapidly to the brain. Although its popularity is de- Europe in the mid-nineteenth century. The novelty clining in the United States, cigarette use is increas- came to dominate the industry over a period of ing worldwide at over 2 percent per year, especially forty years, from the mid-1880s to the mid-1920s, in much of Asia, Eastern Europe, and the former when, for the first time, more tobacco in the United Soviet Union. An integrated system of suppliers, States was used for cigarettes than for chewing to- manufacturers, marketers, and sales outlets is con- bacco. stantly evolving to supply this vast and growing A number of changes in the nineteenth century market. In the past, sophisticated legal and lobby- laid the groundwork for the cigarette’s commercial ing enterprises managed to protect this industry success. The development of flue-cured tobacco from the sort of regulation advocated by a number and air-dried burley tobacco—easily processed of public health groups—regulations that govern- into tobaccos for smoking (where the smoke might ments routinely impose on far less toxic products, be inhaled) were major factors (Slade, 1993). Ciga- but an admonition from an internal source as to the rette-making machines—first used commercially in 1883 by the American Tobacco Company—the effects of tobacco led to a dramatic increase of development of safe matches, and an extensive rail- public and regulatory pressure on the tobacco in- road network to transport centrally manufactured dustry. cigarettes throughout the United States were among the other key factors responsible for this PRIVATE ENTERPRISE VERSUS product’s success. STATE MONOPOLY Duke of Durham, North Carolina. These elements were successfully harnessed by Benjamin Tobacco (nicotiana) is a plant of the nightshade Newton (Buck) Duke, head of the American To- family (genus Nicotiana) and is native to the Amer- bacco Company. A working cigarette-making ma- icas; it was a major commodity of commerce in chine had been invented in 1881 by James Bonsack colonial times. Cigar tobaccos were key exports in response to a contest held by the cigarette maker from the Spanish and Portuguese colonies of the Alan & Ginter of Richmond, Virginia (Smith, Caribbean and South America, while tobaccos for 1990). But the contest sponsors decided against snuff, pipe, and chewwerethe economic mainstays using the invention since they did not knowhowto of the English colonies in Virginia, Maryland, and sell as many cigarettes as the machine was capable the Carolinas. Whereas most of Europe (and the of making. Duke, however, realized that the low rest of the world) established state-run monopolies prices made possible by mass production, together for tobacco distribution, private enterprise was the with advertising to stimulate demand, would create vehicle of tobacco commerce in Great Britain (and a large enough market to absorb the vastly ex- eventually in the United States). The state monopo- panded production. He obtained favorable terms lies provided both a popular product for the popu- for using the machine in exchange for technical lace and revenue for the national treasury—but assistance in perfecting it. The machine Duke put on line in 1883 produced 120,000 cigarettes per private enterprise, which always paid excise tax in day, the equivalent of 60 expert hand rollers. Great Britain, was more resourceful in expanding Duke’s competitors had to pay more for Bonsack the market. This phenomenon was exploited in the machines than he had, and Duke engaged in price twentieth century and was especially apparent in wars to further weaken other manufacturers. Grad- the 1990s, with the remaining state monopolies ually, he bought out his competitors and monopo- becoming privatized and adopting the marketing lized the U.S. cigarette industry. By 1890, Duke techniques of the by-nowenormous transnational controlled the cigarette market, and by 1910, just tobacco companies, often actually merging with before his monopoly was broken, he controlled them. more than 80 percent of all tobacco products man- 1094 TOBACCO: INDUSTRY ufactured in the United States, except for cigars brands of the time, such as Fatima, sold for fifteen (Robert, 1952). cents per pack of twenty, a pack of Camel sold for a Seeking further growth, Duke began to expand dime. In short order, Camel overwhelmed the com- his cigarette business overseas (Robert, 1952). By petition and ushered in a dramatic expansion of the 1900, a third of America’s domestic production domestic cigarette market. American Tobacco cop- was being sent to Asia, and company factories were ied the Camel formula with Lucky Strike, and Lig- operating in Canada, Australia, Germany, and Ja- gett & Myers followed with its copycat product pan. In 1901, Duke purchased a cigarette factory in Chesterfield. Cigarette cards, premiums, and cou- Liverpool, England. Alarmed British manufactur- pons were abandoned in favor of the mass media, ers, seeking to avoid the fate of their U.S. com- and prices fell. Cigarette use, then only rising patriots, banded together as the Imperial Tobacco slowly, began an unprecedented increase. This Company. The resulting trade war between Ameri- growth continued virtually unabated for forty years can and Imperial ended in a truce. American was or so, until finally slowed and eventually reversed given exclusive trading rights in the United States by alarms that lung cancer and other major dis- and Cuba, and Great Britain became Imperial’s eases could be caused by cigarettes (Fiore et al., exclusive territory. A newcompany, jointly con- 1993). trolled by both giants, was to sell cigarettes to the Only two firms that had no roots in the tobacco rest of the world. This modest sinecure was the trust have played major roles in the U.S. cigarette birthright the parent companies gave the British- market (Sobel, 1978). After Buck Duke’s death in American Tobacco Company (BAT). 1929, BAT purchased the Brown & Williamson Antitrust Litigation. In 1907, the U.S. gov- Tobacco Company in Louisville, Kentucky. BAT ernment filed an antitrust case against the Ameri- gradually built this company into a major cigarette can Tobacco Company. The result of this litigation producer. For decades, its Kool brand dominated was the dissolution of the trust four years later into the menthol category, and during the 1930s and a number of successor companies, some of which 1940s, its Wings brand gained market share by retain major roles in the U.S. cigarette market. undercutting the prices of the majors. Brown & These companies were the American Tobacco Williamson continues to offer a full range of ciga- Company, the R.J. Reynolds Tobacco Company, rettes for the U.S. market. It also produces ciga- Liggett & Myers, and P. Lorillard. rettes for export to many of BAT’s international Once it had emerged from the confines of the markets. trust, R.J. Reynolds, which had never before made The other upstart company was Philip Morris, cigarettes, developed and introduced Camel, a which began its U.S. operations as a specialty ciga- novel brand, in 1913 (Tilley, 1985). Camel was the rette maker in NewYork in the first quarter of the first brand to combine air-dried burley, which had century. In addition to its standard brand called previously been important in chewing-tobacco Philip Morris, it produced Marlboro—a cigarette products, with the then-conventional cigarette to- for ‘‘ladies.’’ The company expanded in the 1930s baccos—the flue-cured and Turkish (Oriental) va- with a low-priced brand (Paul Jones) and a clever rieties (Slade, 1993). Camel featured a coherent, pricing scheme for Philip Morris English Blend national advertising campaign from N.W. Ayer that (Robert, 1952; Sobel, 1978). It suggested a retail relied entirely on mass-media outlets in magazines price for the latter slightly above that for the major and on billboards instead of on package-based pro- brands, but it gave retailers a larger margin, thus motions such as cigarette cards, coupons, and pre- encouraging prominent display of the brand in miums. The legacy of this startling departure from stores. In the mid-1950s, Philip Morris gave Marl- the conventional cigarette-marketing techniques of boro a filter and had the Leo Burnett advertising the time is captured by the sly legend that still agency remake its image entirely to one of rugged graces each pack of twenty unfiltered Camels sold masculine outdoor daring on horseback. (The en- in the United States: ‘‘Don’t look for premiums or tire sweep of Marlboro advertising is included in coupons, as the cost of the tobaccos blended in the special advertising collection of the American CAMEL Cigarettes prohibits the use of them.’’ Museum of National History in Washington, D.C.) The other thing that distinguished Camel from By the mid-1970s, Marlboro was the leading U.S. its competitors was its price. While the leading cigarette and by the 1990s, thanks to the strength TOBACCO: INDUSTRY 1095 of Marlboro’s appeal to teens and young adults, Table 1 lists the major tobacco-product manu- Philip Morris overtook R.J. Reynolds to become the facturers in the United States, the location of their nation’s largest tobacco-product manufacturer. corporate headquarters, and the major tobacco Smokeless Tobacco. Moist snuff and chewing brands they market. tobacco enjoyed a 1980s and 1990s resurgence in popularity—this is based on the successful efforts INNOVATION of U.S. Tobacco (UST). It sells oral tobacco (e.g., The tobacco industry adapts to changing cir- Skoal Bandits, Skoal, Copenhagen) to adolescents cumstances in many ways. Product innovation is a and preadolescents (Denny, 1993). Oral tobacco is key strategy. Since the early 1950s, the major the only category of tobacco product whose con- changes in cigarette design have come in response sumption has increased in recent years in the to public-health concerns that cigarettes constitute United States. This increase is attributable to a leading cause of illness and death (McGinnis, UST’s innovative marketing of moist snuff to ado- 1993; Slade, 1993). Most of these innovations have lescent boys, and to imitation products from other been variations on filters and so-called low-tar de- manufacturers. Although UST envisions a global signs. Ballyhooed with multibillion-dollar advertis- market for snuff, the World Health Organization ing budgets, these innovations propped up cigarette has declared that countries in which oral tobacco is consumption over the years despite the complete not a traditional product should ban it. A number absence of demonstrated benefit at the time they of countries—including Australia, NewZealand, were introduced. Years of study (and as many years Hong Kong, and the European Community—have of unregulated sale) have only produced evidence taken this step, often defying intense pressure from for decidedly marginal benefits, yet the innovations the U.S. government when doing so. have become firmly established. These supposed 1096 TOBACCO: INDUSTRY advances have been criticized by some as being nating a formerly self-contained market through nothing more than public relations gimmicks in the product innovation, smuggling, aggressive adver- face of and in mocking response to profound pub- tising, and pricing policies. The result is a larger lic-health problems. market for tobacco products than existed previ- The cigarette companies continue to invent ously and a corporate management that is better novel ways to deliver nicotine to the brain. Elec- able to oppose public-health efforts at regulation tronic devices, smokes with charcoal fuel elements, and control. Although cigarette consumption is and tiny aerosol cans are but some of the gimmicks down in the United States, Canada, and Western the companies have patented to facilitate the inha- Europe, it is rapidly growing in most of the world— lation of nicotine. Despite these efforts, the industry especially the so-called third world. The transna- remains dependent on smoking, with variations of tional companies have positioned themselves to the tobacco-filled cigarette the mainstay of its busi- both fuel and profit from this trend. ness for the foreseeable future. DIVERSIFICATION INTERNATIONAL EXPANSION The giant cigarette makers have invested their Cigarette smoking has been declining in the tobacco profits in other enterprises for more than United States, Canada, and Western Europe. Since twenty years, ranging from soft drinks and cookies the 1960s, however, the biggest cigarette manufac- to office products, insurance, and real estate. This turers (BAT, Philip Morris, RJR/Nabisco, and, re- process has resulted in the ownership by tobacco cently, Japan Tobacco Incorporated) have steadily companies of some widely known consumer-prod- increased their business in international markets uct companies, including Kraft and Nabisco. Al- (Taylor, 1984). This expansion has been accompa- though the parent tobacco companies pretend that nied by the weakening and dissolution of both na- this phenomenon makes them somehowless in- tional private and state-owned tobacco companies. volved in tobacco (none nowhave the word‘‘to- The process got under way in Latin America in the bacco’’ in their corporate name), a thoughtful ex- 1960s, spread to eastern Asia in the late 1980s, and amination of these businesses reveals the following: developed into a frenzy of deal making in Eastern Europe and the republics of the former Soviet Tobacco products remain by far the most pro- Union in the early 1990s (Shepherd, 1985; Sesser, fitable sector of each of these conglomer- 1993). ates; and tobacco products are always re- Shepherd has described the process whereby a sponsible for most of the company profits transnational corporation moves toward domi- (see Tables 2 and 3). TOBACCO: INDUSTRY 1097

Not one of these companies has backed away tury dominance of the market by Camel. In the from any available opportunity to sell to- 1930s, price competition, made possible by overly bacco products. Indeed, the strongest aggressive price increases by the majors, contrib- companies continue to invest in domestic uted to the emergence and growth of Brown & and overseas ventures that have as their Williamson and Philip Morris (Sobel, 1978). From goal the expansion of tobacco consump- the end of World War II (1945) until 1980, how- tion. ever, price competition was virtually absent from These companies make ready use of the U.S. cigarette market. nontobacco subsidiaries to support their In 1980, tiny Liggett & Myers, a firm that had tobacco businesses. For example, RJR/ become too small to enjoy oligopolistic profits, Nabisco fired the ad agency that did their broke ranks with its fellows by introducing generic Oreo Cookie advertising after that agency cigarettes. The strategy was made possible by the also produced ads promoting an airline pattern of price increases in the industry— offering smoke-free flights. Philip Morris increases that had exceeded the rate of inflation for has used one of its Kraft-General Foods warehouses for its coupon-redemption years. Brown & Williamson soon followed suit with program for the Marlboro Adventure its own generic brands, and within a few years Team. every cigarette manufacturer had a multitiered pricing structure, with the heavily advertised, stan- Tobacco companies do not diversify to get out of dard brands at the top. Prices for the major brands the tobacco business. They diversify because to- continued to rise steeply, far faster than inflation, bacco has given them profits, the acquisitions seem through early 1993. Customers who might have sound investments, and the resulting product mix stopped smoking because of high prices were kept complements the core business in some manner. in the market by the increasingly available lower priced offerings. By early 1993, however, invest- PRICE WARS ment analysts had become concerned because Price competition has long been part of the to- lower priced brands accounted for more than 25 bacco industry strategy. It was the major tool for percent of all cigarette purchases—with attendant the achievement of monopoly power in the 1880s threats to profits—and Philip Morris had become and was a key element in the early twentieth-cen- alarmed by the market share losses sustained by its 1098 TOBACCO: INDUSTRY cash cow, Marlboro, to less than 25 percent of all research, they did in fact do so, but their conclu- cigarettes sold. sions, giving more light to the fact that tobacco is Philip Morris had a number of key strengths that addictive and harmful, were not released. Rou- gave it a flexibility not possessed by its competitors, tinely called the ‘‘tobacco cover-up’’ it resurfaced including market leadership, an absence of corpo- in later years with much of its strength coming from rate debt, and a strong youth market for Marlboro. Bennett S. LeBow’s agreeing, in 1997, to put warn- Its principal competitor, RJR/Nabisco, had an ings on cigarette packs stating that smoking is ad- enormous corporate debt—and although Camel dictive. Leaked internal documents also served as had been making inroads into Marlboro’s youth evidence of the dangers. In 1998, however, other market, it was still far from the dominant cigarette. tobacco companies still contested that tobacco was These factors led Philip Morris to cut prices sub- not an addictive drug. Discovery, through LeBow, stantially (while mounting the most elaborate proof the industry’s nondisclosure and the understand- motional campaign ever seen in the industry). The ing that the industry had evidence of the thereat of competition was forced to follow suit with lower smoking, however, caused severe public attacks on prices. Marlboro’s brand share surged; the threat to the tobacco industry to be more common. Public profitability from lower priced brands subsided; campaigns have also been more potent with reduc- and the competition was left somewhat weakened. ing youth smoking. Between 1998 and 2000 smoking had declined 54 percent in middle schools and LOBBYING AND PUBLIC RELATIONS 25.2 percent in high schools. Recently tobacco advertising legislation has weakened the strength of In 1915, the U.S. tobacco industry formed the tobacco propaganda among youth populations, by Tobacco Merchants Association (TMA) to lobby banning all advertising that is determined to be too against the anticigarette laws that had become a appealing to a minor. More legislation is in being problem for the industry in a number of states proposed and being worked on to make nicotine a (Robert, 1952). These laws came about as a result drug regulated by the FDA. Previously, the FDA of the efforts of antitobacco advocates, including has tried to apply regulations to tobacco and ciga- Henry Ford and Thomas Edison. The TMA accom- rettes as a nicotine delivery agent, but the courts plished its objectives: By 1930, the state prohibi- had determined that Congress had not yet given the tions on cigarettes had been diminished to easily regulatory administration such authority, so new ignored prohibitions that only barred the sale of legislation must be passed for successful and lawful cigarettes to minors. regulation. If such a bill is passed tighter control In the 1950s, the industry faced a more substan- will be possible so that tobacco can be prohibited in tial challenge—proof that cigarettes caused lung public events where minors may be part of the cancer. In addition to putting cosmetic filters on the targeted demographic, in response to public outcry. product and making outrageous claims for their Furthermore, tobacco companies are prohibited benefit (P. Lorillard trumpeted its asbestos-filtered from sponsoring public events and athletic compe- Kent as ‘‘the greatest health protection in cigarette titions. In some states, legislation has also already history’’), the industry developed a sophisticated been passed, and tried, winning large cash settle- public relations and lobbying capability (Wagner, ments to recover lost health costs suspected to be to 1971). The public relations firm of Hill & tobacco use related. Included in some of these set- Knowlton organized the Tobacco Institute to meet tlements have also been requirements for the to- the industry’s public relations and lobbying needs. bacco companies to pay for more advertisements, The cigarette makers also formed the Tobacco In- but these advertisements are intended to reduce dustry Research Committee (later reorganized and youth smoking. Despite the research, such as it renamed the Council for Tobacco Research) to cre- was, the mounting costs to the tobacco companies ate the pretense that the industry was conscien- because of lawsuits and penalties, and in the face tiously involved in biomedical research to get to the of growing evidence of harm from a variety of other bottom of the smoking and health question (Freed- quarters, the smoking epidemic continues. man & Cohen, 1993). The Tobacco Institute, in alliance with the vari- Although speculation existed as to howdili- ous branches of the industry, has stood as a gently the tobacco industry would pursue smoking bulwark against public-health activities for a gen- TOBACCO: INDUSTRY 1099

eration. The Council for Tobacco Research has FIORE, M. C., NEWCOMBE, P., & MCBRIDE, P. (1993). funded studies of marginal importance for public Natural history and epidemiology of tobacco use and relations gain while operating a Special Projects addiction. In C. T. Orleans & J. Slade (Eds.), Nicotine branch for the benefit of tobacco-product liability addiction: Principles and management. NewYork: defense. In these and other ways, the tobacco in- Oxford University Press. dustry has attempted to insulate itself from signifi- FREEDMAN, A. M., & COHEN, L. P. (1993, February 11). cant regulation and from acceptance of any respon- Howcigarette makers keep health question ‘‘open’’ sibility for the harm its products cause. Similar year after year. Wall Street Journal, p. A-1. organizations exist to protect the interests of oral- GANSKE, Rep. [IO] ‘‘The Nation’s Number One Health tobacco manufacturers. Problem.’’ Congressional Record ONLINE 5 April 2000. GPO Access. Available: http:// OWNERSHIP frwebgate5.access.gpo.gov. The major tobacco-product manufacturers are MCGINNIS, J. M., & FOEGE, W. H. (1993). Actual causes publicly owned and traded corporations. As such, of death in the United States. Journal of the American they are owned by their investors. Major institu- Medical Association, 270(18), 2207–2212. tions, including banks, insurance companies, and MISHRA, Raja, Knight-Ridder/Tribune News Service, To- pension funds, hold the majority of shares in the bacco CEO’s refuse to be pinned down on whether tobacco industry. tobacco is addictive, Feb 24, 1998. ROBERT, J. C. (1952). The story of tobacco in America. SUMMARY AND CONCLUSION NewYork: Alfred A. Knopf. STATE LEGISLATURES, States try to recoup health costs of The tobacco industry is a powerful oligopoly of smoking, March 1996 v22 n3. product manufacturers in alliance with a network SESSER, S. (1993). Opium war redux. The New Yorker, of suppliers and associated service organizations. 69(29), 78–89. Although its products form the leading cause of SHEPHERD, P. L. (1985). Transnational corporations and preventable death, it continues despite public senti- ment and attempt to protect itself against appropri- the international cigarette industry. In R. S. ate regulation by extensive legal, public relations, Newfarmer (Ed.), Profits, progress and poverty. Notre and lobbying efforts. The industry is understand- Dame, IN: University of Notre Dame Press. ably driven by an interest in making money. It has SLADE, J. (1993). Nicotine delivery devices. In C. T. never acted out of a primary concern for the health Orleans & J. Slade (Eds.), Nicotine addiction: Princi- of its customers or the health of those around them. ples and management. NewYork: Oxford University For a variety of reasons, including clever interven- Press. tion by the industry, government has utterly failed SMITH, J. W. (1990). Smoke signals. Richmond, VA: The to provide the sort of regulatory control expected Valentine Museum. when it comes to something as addicting and toxic SOBEL, R. (1978). They satisfy. Garden City, NY: Anchor as nicotine-containing tobacco products until a Press/Doubleday. critical documentation leak occurred from within TAYLOR, P. (1984). The smoke ring: Tobacco, money, the companies of the tobacco industry. and multi-national politics. NewYork: Pantheon. TILLEY, N. M. (1985). The R.J. Reynolds Tobacco Com- (SEE ALSO: Advertising and Tobacco Use; Nicotine) pany. Chapel Hill: University of North Carolina Press. ‘Truth’ puts dent in Florid teen smoking, Adweek, March BIBLIOGRAPHY 6, 2000. WAGNER, S. (1971). Cigarette country. NewYork: BROOKS, J. E. (1949). The mighty leaf. NewYork: Little, Praeger. Brown. WAXMAN,REP. [CA]. Congressional Record. ONLINE 21 CANNON, Angie. Liggett owner settles lawsuits by agreeing to warn smokers that tobacco is addictive, Knight- March 2000. GPO Access. Available: http:// Ridder/Tribune News Service, Mar 20, 1997. frwebgate5.access.gpo.gov. DENNY, J. (1993). The king of snuff. Common Cause JOHN SLADE Magazine, 19(2), 20–27. REVISED BY ANDREW J. HOMBURG 1100 TOBACCO: MEDICAL COMPLICATIONS

TOBACCO: MEDICAL COMPLICA- bronchial catarrh, and so emphysema of the TIONS lungs.’’ In general, Rolleston observed that considering ‘‘the large number of heavy smokers, the HISTORY comparative rarity of undoubted lesions due to smoking is remarkable.’’ He concluded that ‘‘to The notion that smoking tobacco is injurious to regard tobacco as a drug of addiction may be all the body is not of recent origin. King James I of very well in a humorous sense, but it is hardly England, in his classic ‘‘Counterblaste to To- accurate.’’ bacco,’’ written in 1604, outlined a number of be- But even as Rolleston was lecturing, researchers liefs about tobacco’s ill effects on health and urged were looking at the evidence suggesting that smok- his subjects to avoid it. He called smoking a ‘‘filthie ing was responsible for the increasing number of noveltie . . . A custome lothsome to the eye, hatefull lung cancer cases, a rare disease in the nineteenth to the nose, harmefull to the braine, dangerous to century. Within thirty years there would be a grow- the Lungs. . . .’’ Opinions on the possible benefits ing consensus among the medical scientific commu- and health damage caused by use of tobacco varied nity that tobacco smoking was the principal cause over the next 300 years. Some nineteenth-century of lung cancer, causally related to other cancers, arguments that tobacco use injured health were and a major contributor to cardiovascular diseases, linked to moral arguments against its use rather peripheral artery disease, and chronic obstructive than to what today would be considered medical lung disease (emphysema and chronic bronchitis). evidence. Yet from the 1920s to the 1960s, cigarette smoking In 1926 Sir Humphrey Rolleston of Cambridge gained almost universal social acceptance. Using University (the same ROLLESTON who headed the doctors and nurses and health-related slogans committee on the use of opioids) addressed the (‘‘not a cough in a carload’’) in their advertise- Harrogate Medical Society on the subject of medi- ments, cigarette manufacturers implied that ciga- cal aspects of tobacco and the possible toxic effects rette smoking was without health risk. By the of nicotine. He drewfewfirm conclusions. Only a 1960s the majority of adult males were smokers, fewhealth problems wereclearly linked to tobacco. with more than 70 percent in some age groups. These included some irritation of the throat and The turning point in the public’s perception of upper air passages by furfural, pyridine deriva- the adverse consequences of tobacco smoking came tives, ammonia, and carbon monoxide, which he with the publication of the Report of the Royal ascribed to combustion of vegetable material and College of Physicians in England in 1962 and the ‘‘not, like NICOTINE, in any way special to to- Report of the Surgeon General in the United States bacco.’’ He did mention tobacco amblyopia, a dis- in 1964. These two reports documented the experi- order of the optic nerve leading to blindness, now mental, epidemiological, and pathological evidence thought to be a rare complication. Among the heart linking tobacco smoking to a variety, of diseases, disorders Rolleston mentioned were extrasystoles the most notable of which were lung cancer, illness (irregular heartbeats) and angina (pain caused by and death from heart disease, and chronic bronchi- insufficient blood reaching the heart). He noted tis and other lung disorders. Many more reports on that nicotine constricted coronary arteries but sug- the health consequences of smoking followed these gested that people who suffered from extrasystoles two pivotal publications. Since 1969 the Office of might consider giving up coffee and tea before to- Smoking and Health of the U.S. Public Health bacco. He observed that cigarette smoking could Service has coordinated the annual publication of a cause arterial spasms, noting that it was linked to Surgeon General’s Report on the health conse- obliterative diseases of the large arteries among quences of smoking, with several of the reports young Jews living in London’s East End. Rolleston focusing on specific topics. In approaching such believed that cancers of the lip and oral cavity ob- major reviews of specific health consequences of served in smokers were probably caused by syphilis smoking, the Office of Smoking and Health assigns and therefore not firmly linked to smoking. He recognized experts to reviewand summarize all the devoted only a fewlines to smoking’s adverse ef- existing scientific literature on the topic and then fects on the respiratory tract, observing that smok- drawsome conclusions from it. Some of the special ing was responsible for ‘‘causing cough, hoarseness, topics that have been considered are health conse- TOBACCO: MEDICAL COMPLICATIONS 1101 quences of smoking for women (1980), the changing cigarette (the implications for health of lowtar/ nicotine cigarettes and filters) (1981), chronic obstructive lung disease (1984), cancer and chronic lung disease in the workplace (1985), and nicotine addiction (1988). The 1972 report was the first to explore the health consequences of involuntary smoking (passive or secondhand smoking). The 1979 and 1989 reports were overall reviews of the field, marking the fifteenth and twenty-fifth anniversaries of the landmark 1969 report produced when Dr. Luther Terry was Surgeon Gen- eral. The 1979 report described tobacco smoking Metastatic melanoma in the lung, magnified 450 as ‘‘the largest preventable cause of death in Amer- times. ( Lester V. Bergman/CORBIS) ica.’’ It noted that statisticians were able to identify the following as deaths related to smoking: 80,000 Pure nicotine is a poison that can kill within each year from lung cancer; 22,000 from other minutes by causing respiratory failure. Nicotine cancers; up to 225,000 from cardiovascular disease; and more than 119,000 from chronic pulmo- poisoning most commonly results from accidental nary disease. As of 2000, cigarette smoking re- ingestion of insecticides containing nicotine. A fatal mained the most important cause of preventable dose of nicotine for an adult is 40 to 60 mg. disease and premature death in the developed Cancer. Tobacco smoking has been shown to countries of the world. It is estimated that, depend- be the major cause of lung cancer in both men and ing on the age at which a person starts to smoke, 7 women. The increased risk for lung cancer is di- to 13 years of life are lost to smoking-related dis- rectly related to the amount smoked. The risk of eases. Nonetheless, nearly 47 million Americans death from lung cancer is about twenty times continue to smoke. greater for men who smoke two packs a day than for those who have never smoked. It is about ten TOBACCO-RELATED DISEASES times higher for those who smoke one-half to one pack a day. Depth of inhalation also influences risk The Pharmacological Actions of Nicotine. of disease. Tobacco smoking is synergistic (pro- Nicotine, the addictive component in tobacco, is a duces a multiplier effect) with the effects of other colorless liquid alkaloid that turns brown and be- carcinogenic risks, such as exposure to radon or gins to smell like tobacco when it is exposed to air. asbestos. Smoking is also synergistic with alcohol in In addition to the psychological and social dimen- causing cancers of the oral cavity, larynx, pharynx, sions of tobacco dependence, nicotine by itself pro- and esophagus. duces reinforcement. It has both stimulant and Cardiovascular Disease. Smoking is one of depressant effects on the body, and stimulates the three major causes of coronary heart disease release of endogenous opioids. Nicotine has negative as well as positive reinforcement effects. Nega- (CHD); risk of death from CHD is 70 percent tive reinforcement refers to the fact that smoking higher for men who smoke, with a similar effect for for some persons is related as much to avoidance of women. The risk due to smoking increases if there the discomfort of nicotine withdrawal as to seeking are risk factors present such as hypertension and the pleasurable effects of nicotine. elevated cholesterol levels. Smoking increases risk Nicotine is quickly absorbed through the skin, for stroke. For example, women who smoke mucous membranes, and lungs. Absorption twenty-five cigarettes or more per day have a risk through the lungs produces measurable effects on for stroke almost four times higher than nonsmok- the central nervous system in as little as 7 seconds. ers. Smoking also increases the risk of atherosclero- This rapid rate of absorption means that each puff sis (formation of plaques) in the peripheral arteries on a cigarette produces some reinforcement of the and the aorta. In peripheral arteries this condition smoking habit. can lead to insufficient oxygen reaching the mus- 1102 TOBACCO: MEDICAL COMPLICATIONS cles; in the aorta it can lead to a rupture that is Category D. Diseases for which excess mortality in usually fatal. smokers has been observed but for which this ob- Lung Disease. The link between tobacco servation is attributed to confounding variables smoking and chronic obstructive pulmonary dis- (other factors that are commonly found among ease (COPD) was noted in the 1964 Surgeon Gen- smokers): alcoholism; cirrhosis of the liver; poison- eral’s Report. COPD includes three related disor- ing; suicide ders: chronic mucous hypersecretion that causes Category E. Diseases for which smokers have lower cough and phlegm production; airway thickening death rates than nonsmokers: endometrial cancer; and obstruction of expiratory airflow; and emphy- Parkinson’s disease; ulcerative colitis sema—abnormal dilation of air sacs and destruc- The effects of tobacco use are not limited to tion of walls of the alveoli. Compared to nonsmok- specific diseases that lead to death. Tobacco use ers, male smokers are three times more likely and can stimulate enzymes in the liver, and this stimu- female smokers are twice as likely to have a persis- lation can result in alterations in the way various tent cough. medications are metabolized. This alteration in me- Other Medical Disorders. These include tabolism can mean that the levels of medications in peptic ulcers, upper respiratory infections, osteopo- the body will not be high enough to be optimally rosis, and cancers of the pancreas, bladder, and therapeutic. esophagus. The overall increased mortality from smoking The toxic properties and carcinogenic effects of varies with the amount smoked. For those who tobacco smoke and its constituents have been stud- smoke two or more packs of cigarettes per day, it is ied in the laboratory using animals. The evidence about double that of nonsmokers; for those who smoke less, it is about 1.7 times higher than for linking tobacco use to death and disease in hu- nonsmokers. The risk for various diseases can be mans, however, relies heavily on epidemiological powerfully affected by cessation, but not all risks studies comparing the rates of various diseases as decline at the same rate. Cardiovascular disease they occur in smokers versus nonsmokers, in light risk decreases markedly within a year of quitting versus heavy smokers, and in continuing versus smoking; risks of cancer decline more slowly, with former smokers. The level of certainty that links some elevated risk still evident ten years after ces- tobacco use to a particular disease varies. Shopland sation. By ten to fifteen years after quitting, overall and Burns (1993) have grouped diseases according mortality of former smokers is not much higher to their established epidemiological association than that of nonsmokers. Increased mortality rates with cigarette smoking in five categories. These are are not as marked for pipe and cigar smokers, but outlined below. they are still substantially elevated. The mortality Category A. Diseases for which a direct causal asso- risk for users of smokeless tobacco comes primarily ciation has been firmly established and smoking is from cancers of the oral cavity and throat. considered the major single contributor to excess The adverse effects of passive inhalation (sec- mortality from the disease: cancers of the lung, ond-hand smoke) are not considered here except in larynx, pharynx (oral cavity), and esophagus; connection with the higher incidence of respiratory chronic obstructive pulmonary disease, including illness among the infants of mothers who smoke. emphysema; peripheral vascular disease But there is no question that there are differences in Category B. Diseases for which a direct causal composition of mainstream smoke (the smoke in- association has been firmly established but for haled by the smoker), sidestream smoke (produced which smoking is only one of several causes: stroke; by tobacco burning between puffs), and environ- coronary heart disease; cancers of the bladder and mental smoke (the mixture of exhaled mainstream pancreas; aortic aneurysm; perinatal mortality and sidestream smoke). Sidestream smoke is pro- Category C. Diseases for which an increased risk duced at lower combustion temperatures and has (association) has been demonstrated but a risk higher concentrations of carbon monoxide and or- whose exact nature has not been firmly established: ganic constituents believed to be carcinogenic. cancers of the cervix, uterus, stomach, and liver; Psychiatric Disorders. Dependence on to- gastric and duodenal ulcers; pneumonia; sudden bacco is associated with dysthymic disorder and infant death syndrome other forms of depression. It is not yet known, how- TOBACCO: MEDICAL COMPLICATIONS 1103 ever, whether depression prompts people to begin ery, are lower for babies of women who smoked smoking or whether it develops in the course of during pregnancy. Women who stop smoking early dependence on tobacco. Mood disorders increase in pregnancy increase their likelihood of having significantly during withdrawal from nicotine, and normal deliveries and normal-birth-weight babies. are common reasons for relapse. Interestingly, epidemiological data suggest that passive smoke exposure during pregnancy (e.g., WOMEN AND SMOKING living with a smoker) can adversely affect birth weight of the baby. Infants born to mothers who Women who smoke tobacco have the same risks smoke are far more likely to die before their first for adverse effects as men. The early impression birthday, primarily as a result of respiratory com- that women suffered fewer adverse effects from plications and sudden infant death syndrome. Chil- smoking was really due to lower levels of exposure dren of mothers who smoke seem in general more (fewer women smokers and a tendency of women likely to suffer from colds, asthma, bronchitis, smokers to smoke less heavily.) As has been written pneumonia, and other respiratory problems. more than once, women who smoke like men die Efforts to educate the public about the health like men. In 1986 deaths due to lung cancer among consequences of smoking, including smoking-pre- women exceeded deaths from breast cancer, be- vention programs directed at young people and coming the leading cause of cancer death for encouragement of smokers to quit, have led to a women. Some women are at special risk. It has been reduction in the prevalence of smoking in the documented that while the use of oral contracep- United States and in several European countries tives alone does not constitute a serious health risk, since the mid-1960s. In general, white males in the combination of oral contraceptives and ciga- higher socioeconomic groups have lowered their rette smoking raises substantially the risk of car- smoking rate more than women and members of diovascular disease, including subarachnoid hem- ethnic and racial minorities and lower socioeco- orrhage (bleeding inside the skull). nomic groups. By the early 1960s lung cancer Women who smoke have higher infertility rates deaths among African-American men exceeded than those who do not and are also more likely to those among white men; by 1990 it was 30 percent have menstrual irregularities. Nicotine crosses the higher. The lung cancer rate among both African- placenta, and because it constricts blood vessels, a American and white women was virtually the same, decreased amount of oxygen is delivered to the reflecting similar smoking patterns. On the other fetus. In addition, smoking elevates the amount of hand, smoking rates are increasing in younger age carbon monoxide in the mother’s blood so that it groups in the United States. The rates of smoking carries less oxygen to the fetus. Women who smoke have increased from 34.6 percent of the young during pregnancy have higher rates of premature adult population (aged 18–25) in 1994 to 40.6 detachment of the placenta (abruptio placentae), percent in 1997 and 41.6 percent in 1998. An esti- premature rupture of membranes, and preterm de- mated 18.2 percent of young people in the 12–17 livery. The greater the amount of tobacco smoked age bracket were smokers in 1998. during the pregnancy, the higher the frequency of In contrast to the general decline of smoking in spontaneous abortion and fetal death. In the United the West, the prevalence of smoking may actually States smoking has been associated with a 20 per- be increasing in developing and newly industrial- cent increase in preterm births among women who ized countries where, even among medical stu- smoked a pack a day or more compared with those dents, cigarette smoking retains a cachet of sophis- who did not smoke. tication and affluence. There is no consensus on whether smoking increases the probability of congenital malforma- (SEE ALSO: Advertising and Tobacco Use; Compli- tions. However, it is well established that babies cations; Nicotine; Treatment: Tobacco) born to women who smoke during pregnancy weigh on average about seven ounces less than those born BIBLIOGRAPHY to nonsmokers. Apgar scores, a composite of measurements of the breathing, skin color, and reflexes BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck of infants taken at one and five minutes after deliv- manual of diagnosis and therapy, 17th ed. 1104 TOBACCO: SMOKELESS

Whitehouse Station, NJ: Merck Research Laborato- The use of tobacco was brought to Europe by ries. Columbus and other explorers, where it was taken COOK, P. C., PETERSEN, R. C., & MOORE, D. T. (1994). up for recreation in both the smoked form (cigars Alcohol, tobacco, and other drugs may harm the un- and pipes) and the smokeless. Smokeless tobacco born. Rockville, MD: U.S. Department of Health and (ST) became popular in British society in the prac- Human Services, Public Health Service. tice called sniffing, but British colonists in the CORTI, E. (1932). A history of smoking. Translated by P. Americas preferred to chewtobacco or use snuff. In England, NewYork: Harcourt, Brace. the 1800s, chewing tobacco was widespread in the GRITZ, E. (1980). Problems related to the use of tobacco United States; its use decreased, however, when the by women. In O. J. Kalant (Ed.), Alcohol and drug spitting that resulted (into spittoons or cuspidors or problems in women. NewYork: Plenum. wherever the spit fell) was linked to the spread of HARDMAN,J.G.,&LIMBIRD, L. E. (Eds.) (1996). Good- tuberculosis, one of the most dreaded and fatal of man and Gilman’s the pharmacological basis of ther- diseases. In addition, the mass production of ma- apeutics, 9th ed. NewYork: McGraw-Hill. chine-rolled cigarettes further decreased smokeless NATIONAL CANCER INSTITUTE.(2000). Questions and an- tobacco consumption. Around 1900, 52 percent of swers about finding smoking cessation services. Be- all tobacco used was smokeless; by 1952, that thesda, MD: Office of Cancer Communications. number had dropped to 6 percent (Lewis, Harrell, ROLLESTON, H. (1926). Medical aspects of tobacco. Lan- Deng, & Bradley, 1999). Indeed, the twentieth cen- cet, May 22. tury sawdeclining sales of chewingtobacco until RIGOTTI, N. A., LEE, J. E., & WECHSLER, H. (2000). US about 1970. college students’ use of tobacco products: results of a In the twentieth century, there have primarily national survey. Journal of the American Medical As- been two types of ST: (1) snuff, the type one dips sociation, 284, 699–705. by placing it between the cheek and gum, or SHOPLAND, D. R., & BURNS, D. M. (1993). Medical and (2) chewing tobacco, the type one chews and places public health implications of tobacco addiction. In in the cheek area. Snuff is a cured, ground tobacco C. T. Orleans & J. Slade (Eds.), Nicotine addiction: that comes in three forms: (1) fine-cut tobacco, Principles and management. NewYork: Oxford Uni- (2) moist snuff, or (3) dry snuff (Glover et al., versity Press. 1988; Christen et al., 1982; Christen & Glover, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES 1987). Fine-cut tobacco and moist snuff are used ADMINISTRATION (SAMHSA). (1999). 1998 National by placing a pinch between the cheek and gum or Household Survey on Drug Abuse. Washington, DC: lower lip and gum. Dry snuff may be used by U.S. Department of Health and Human Services. inhaling a pinch through each nostril or by placing a pinch between the cheek and the gum or the lower U.S. DEPARTMENT OF HEALTH,EDUCATION AND WELFARE. (1979). Smoking and health: A report of the surgeon lip and the gum. Chewing tobacco is also produced general. DHEW Publication no. (PHS) 79-50066. in three forms: (1) looseleaf tobacco; (2) plug to- Washington, DC: U.S. Government Printing Office. bacco; or (3) twist chewing tobacco (Christen et al., 1982; Penn, 1902; Christen & Glover, 1987; JEROME H. JAFFE Voges, 1984; U.S. Department of Agriculture, DONALD R. SHOPLAND 1969; Smokeless Tobacco Council, 1984). All three REVISED BY REBECCA J. FREY forms are used by placing a ‘‘chaw’’ in the cheek and periodically chewing. In the 1970s, the use of ST surged in the United TOBACCO: SMOKELESS Since tobacco is States, with smokers showing a preference for moist a plant native to the NewWorld, Native Americans snuff. It is increasingly evident that youngsters and were the first to use it. In addition to smoking it, adolescents are using ST products much more than they used it in smokeless forms—mainly chewing they did in the recent past—of the six million users it, making teas and drinks from it, even using the ST users in the U.S. in 1995, up to 25 percent were ash in rituals that ranged from South America to aged nineteen or younger (Lewis, Harrell, Deng, & Central America and the Caribbean to North Amer- Bradley, 1999). This resurgence of popularity over ica. It was used along with many other plants for the last thirty years has been attributed to innova- both ritual and medicinal purposes. tive advertising campaigns by tobacco companies TOBACCO: SMOKELESS 1105 that used sports superstars, cowboy celebrities, and among kids. NSTEP’s chairman is Hall of Fame entertainers to promote their products. These cam- broadcaster Joe Garagiola, and baseball stars paigns represented an attempt to overcome or erase Frank Thomas and Jeff Bagwell, as well as all-time the old, unsanitary image of the habit, and replace it home run king Hank Aaron, endorse the program. with a manly or ‘‘macho’’ image (Christen et al., County music superstar Garth Brooks did a public 1982; Shelton, 1982; Glover, Christen, & Hender- service announcement supporting the NSTEP son, 1981, 1982). cause, as did Philadelphia Phillies star Lenny NICOTINE, a dependence-producing drug found Dykstra, who had all his teeth pulled because of in ST, is the same drug that is found in smoking overuse of ST. During spring training in 1997, tobacco. Cigarette smokers inhale smoke contain- NSTEP counseled sixteen major league teams on ing nicotine into their lungs, and the nicotine is ST education, providing intervention and cessation then transported into the bloodstream. ST users programs (Walsh et al., 1998). Not only is it impor- absorb nicotine directly through the lining of their tant to help the players quit, of course, but it is mouths. Each time smokers smoke a cigarette, they equally important to reduce the number of absorb approximately 1 milligram of nicotine into ST-using players whom kids idolize and watch ev- their system. By comparison, people who use chew- ery day on cable television. ing tobacco receive approximately 4.5 milligrams NSTEP offers users several tips on quitting ST, of nicotine per chaw, and people who use snuff among them: Be committed, and don’t be discour- receive approximately 3.6 milligrams of nicotine aged by setbacks; quit with a friend or ask for per pinch (Benowitz, 1988). support from non-chewing friends; put three dol- ST is sometimes viewed as a safe alternative to lars in a jar every day to see the financial benefits of cigarettes, but it is not. ST is directly related to a quitting; if tobacco use is sports-related, chewseeds variety of health problems: bad breath, abrasion of or gum instead; and when the quit date is set, visit teeth, gum recession, periodontal bone loss, tooth the dentist for a teeth cleaning, which should help loss, leukoplakia, nicotine dependency, and various forms of oral cancer (Christen, 1985; Schroeder, ease the initial nicotine craving. Chen, & Kuthy, 1985). There are indications that Although survey data indicates that ST is used smokeless tobacco also plays a role in cardiovascu- predominantly by men, it is enjoyed by a number of lar alterations and neuromuscular toxicity (Schroe- women, particularly Native American women, ac- der & Chen, 1985; Squires et al., 1984). cording to Dr. John D. Spangler, researcher at Survey data as of the mid-1980s indicated that Wake Forest University Baptist Medical Center. A predominantly males use smokeless tobacco. In a 2000 study among a group of Eastern Band Chero- large national survey of smokeless tobacco use in kee Indian women in North Carolina found that college, Glover and colleagues reported that about women who used ST were at an eight times greater 22 percent of collegiate males were users of risk of breast cancer than non-users. smokeless tobacco, whereas only 2 percent of collegiate females used it (Glover et al., 1986). In a (SEE ALSO: Adolescents and Drug Use; Advertising study of 5,078 students from 67 high schools and Tobacco Use) throughout the state of Massachusetts, 16 percent of males and 2 percent of females reported using it BIBLIOGRAPHY ‘‘once or twice.’’ Eight and 4 percent of the males studied reported using it ‘‘several times’’ and ‘‘very BENOWITZ, N. L. (1988). Nicotine and smokeless to- often,’’ respectively (McCarty & Krakow, 1985). bacco. CA: A Cancer Journal for Clinicians, 38(4), The increasing numbers of individuals who use 244–247. ST demonstrated a need for education and cessa- CHRISTEN, A. G. (1985). The four most common alteration programs. In 1994, Oral Health America cre- tions of the teeth, periodontium and oral soft tissues ated the National Spit Tobacco Education Program absorbed in smokeless tobacco users: A literature re- (NSTEP) as part of its Oral Health 2000 initiative. view. Journal of the Indiana Dental Association, 64, NSTEP has received the endorsement of Major 15–18. League Baseball and encourages players and users CHRISTEN, A. G. (1980). The case against smokeless to- to quit–but the main goal is to reduce ST use bacco: Five facts for the health professional to con- 1106 TOBACCO: SMOKING CESSATION AND WEIGHT GAIN

sider. Journal of the American Dental Association, SCHROEDER, K. L., CHEN, M. S., JR., & KUTHY,R.A. 101, 464–469. (1985). Smokeless tobacco: The newthing to chew CHRISTEN,A.G.,&GLOVER, E. D. (1987). History of on. Ohio Dental Journal, 59, 11–14. smokeless tobacco use in the United States. Health SCHROEDER, K. L., ET AL. (1987). Bimodal initiation of Education, 18(3), 6–11, 13. smokeless tobacco usage: Implications for cancer edu- CHRISTEN, A. G., ET AL. (1982). Smokeless tobacco: The cation. Journal of Cancer Education, 2(1), 1–7. folklore and social history of snuffing, sneezing, dip- SHELTON, A. (1982). Smokeless sales continue to climb. ping and chewing. Journal of the American Dental Tobacco Reporter, 109, 42–44. Association, 105, 821–829. SMIGHT, T. A. (1981). A man’s chew. Nutshell, 43, GLOVER, E. D., CHRISTEN,A.G.,&HENDERSON,A.H. SMOKELESS TOBACCO COUNCIL. (1984). Smokeless to- (1982). Smokeless tobacco and the adolescent male. bacco. Peekskill, NY: Author. Journal of Early Adolescence, 2, 1–13. SQUIRES, W. G., ET AL. (1984). Hemodynamic effects of GLOVER, E. D., CHRISTEN,A.G.,&HENDERSON,A.H. oral smokeless tobacco in dogs and young adults. Pre- (1981). Just a pinch between the cheek and gum. ventive Medicine, 13, 195–206. Journal of School Health, 51, 415–418. U.S. DEPARTMENT OF AGRICULTURE. (1969). Tobacco in GLOVER, E. D., ET AL. (1988). An interpretative reviewof the United States (Miscellaneous Publication 867). smokeless tobacco research in the United States: Part Washington, DC: Author. 1. Journal of Drug Education, 10, 285–309. VOGES, E. (1984). Tobacco encyclopedia. Mainz: Ger- GLOVER, E. D., ET AL. (1986). Smokeless tobacco use many Tobacco International. trends among college students in the United States. World Smoking and Health, 11(1), 4–9. WALSH, M. M., ET AL. (1998). A dental-based, athletic trainer-mediated spit tobacco program for profes- GLOVER, E. D., ET AL. (1984). Smokeless tobacco research: An interdisciplinary approach. Health Values, sional baseball players. Journal of the California Den- 8, 21–25. tal Association, 26, 365–376. HARPER, S. (1980). In tobacco, where there’s smokeless ELBERT GLOVER fire. Advertising Age, 51, 85. PENNY N. GLOVER HUNTER, S. M., ET AL. (1986). Longitudinal patterns of REVISED BY MATTHEW MISKELLY cigarette smoking and smokeless tobacco use in adolescents: The Bogalusa heart study. American Journal of Public Health, 76, 193–195. TOBACCO: SMOKING CESSATION AND LEWIS, P. C., HARRELL, J. S., DENG, S., BRADLEY,C. WEIGHT GAIN On the average, smokers weigh (1999). Smokeless tobacco use in adolescents: The less than nonsmokers, and approximately 80 per- cardiovascular health in children (CHIC II) study. cent of smokers who quit will gain weight. The Journal of School Health, 69 320–335. average weight gain for smokers who quit is 5 MARTY, P. J., MCDERMOTT, R. J., & WILLIAMS, T. (1986). Patterns of smokeless tobacco use in a population of pounds compared to about 1 pound for continuing high school students. American Journal of Public smokers over the same period, although some quit- Health, 76, 190–192. ters (about 20 percent) will gain more than 10 MAXWELL, J. C., JR. (1980). Maxwell manufactured pounds, and a smaller number (less than four per- products report: Chewing snuff is growth segment. cent) will gain more than 20 pounds. Women tend Tobacco Reporter, 107, 32–33. to gain more weight when they quit smoking than MCCARTY,D.,&KRAKOW, M. (1985, January 28). More men, but the reasons for this are not known. than ‘‘just a pinch’’: The use of smokeless tobacco At least three major issues are important in the among Massachusetts students. Report by the Massa- relationship between smoking cessation and weight chusetts Department of Public Health. Boston: Divi- gain. First, many smokers express fear of gaining sion of Drug Rehabilitation. weight as a reason for not quitting or weight gain as PENN, W. A. (1902). The soverane herbe: A history of a reason for a relapse back to smoking. The data, tobacco. NewYork: Grant Richards Co. however, are not clear that this is the case. Second, SCHROEDER, K. L., & CHEN, M. S., JR. (1985). Smokeless a number of hypotheses have been used to explain tobacco and blood pressure. New England Journal of weight gain in quitters. Finally, because of Medicine, 312, 919. smokers’ stated concerns of weight gain accompa- TOBACCO: SMOKING CESSATION AND WEIGHT GAIN 1107 nying cessation, a number of strategies to reduce or STRATEGIES OF WEIGHT CONTROL delay weight gain have been tested. DURING CESSATION The focus of weight control strategies during FEAR OF WEIGHT GAIN cessation has revolved around diet, exercise, and most recently, pharmacologic agents. Weight con- Fear of weight gain during smoking cessation is trol programs through behavioral self– more common in women who smoke than in men management of dietary intake have been largely who smoke. Among current smokers who have at- ineffective. In two large randomized trials of be- tempted to stop smoking, women also are more havioral weight management during cessation, the likely than men to report weight gain as a with- standard care (control) groups with no weight con- drawal symptom in smoking cessation. Despite trol intervention had better cessation outcomes this, there is not a relationship between weight gain than the groups that received the behavioral inter- concerns and serious smoking cessation attempts vention. One of the studies, however, reported that for either women or men. the amount of weight gained was lower for individ- Research on the effects of weight gain concerns uals receiving the dietary weight control interven- on relapse to smoking has yielded mixed results. tion than individuals not receiving it. Although many unsuccessful quitters cite weight In recent years, a number of research studies gain as the reason for relapse, the majority of stud- examining the effect of physical exercise on weight ies indicate that weight concerns prior to attempt- control during cessation have been conducted. The ing cessation have no relationship to successful majority of these studies have been conducted with quitting. A fewother studies, however,have deter- women. The largest randomized study to date mined a relationship between the two. found that women who participated in exercise as well as a smoking cessation program were twice as likely to be abstinent from smoking 12 months SMOKING CESSATION AND after the program than those who participated in WEIGHT GAIN the smoking cessation program alone. In addition, It is not clear whether weight gain during cessa- the exercise group gained considerably less weight tion is temporary or permanent, although the ma- than the nonexercise group. jority of studies indicate that some weight gain Pharmacologic agents are increasingly used to (about 5 pounds) is likely to be long–term. Al- prevent or delay weight gain during smoking cessa- though the mechanisms responsible for the weight tion. Nicotine itself has been the focus of much gain are not clear, a number of hypotheses have pharmacologic research. The effect of various nic- been set forward. These include a metabolic effect otine replacement delivery systems, such as nic- for smokers; this is supported by research indicat- otine polacrilex gum, the transdermal nicotine ing that smokers and nonsmokers have fewdiffer- patch, nicotine nasal spray, and the nicotine inhaler, on weight gain has been assessed. Nicotine ences in the amount of calories consumed. Another polacrilex gum has been widely studied for its hypothesis is that smoking lowers the body’s ‘‘set weight control effects during cessation. An early point’’ for weight and smoking cessation raises that reviewof five existing studies showedthat gum set point to be equivalent to that of nonsmokers. A users gained less weight than those on a placebo; third hypothesis is based on the observation that an however, the effects were small. Recent randomized increase in caloric intake occurs in those who stop studies of the effects of nicotine gum on weight gain smoking, and increased consumption may be re- suggest that there are no long-term effects of gum sponsible for the weight gain. Although weight gain use on weight gain, and with the discontinuation of is likely to accompany cessation, actual weight gain gum, there are no significant differences in weight during smoking cessation does not appear to be gain between gum users and nonusers. Overall, related to cessation outcomes. Nevertheless, in re- findings are mixed in terms of weight gain during action to smokers’ stated concerns about weight use of the other nicotine replacement products. The gain, a number of strategies to prevent or reduce studies that have been conducted on the nicotine weight gain during cessation have been developed. transdermal patch indicate either no effect or a 1108 TOLERANCE

delayed effect in controlling weight gain during tine. Journal of Consulting & Clinical Psychology, 67, cesssation. Similar findings have been reported for 124–131. the nicotine nasal inhaler. Overall, it appears that CONNOLLY, H.M., ET AL (1997). Valvular heart disease any nicotine replacement effects on weight gain associated with fenfluramine–phentermine. New En- disappear after the nicotine replacement is discon- gland Journal of Medicine, 337, 581–588. tinued. FROOM, P., ET AL (1998). Early and late weight gain in Other pharmacologic agents have also been ex- the Lung Health Study. American Journal of Epidemi- amined for their effects on weight gain during ces- ology, 148, 821–830. sation. In a study of the effects of fluoxetine hydro- FROOM, P., MELAMED,S,&BENBASSAT, J. (1998). Smok- chloride (Prozac) on weight gain during smoking, ing cessation and weight gain. Journal of Family Prac- individuals on the drug gained significantly less tice, 46, 460–464. weight than those on a placebo; however, the fol- HALL, S.M., ET AL (1992). Weight gain prevention and lowup was very short (10 weeks). A study of the smoking cessation: Cautionary findings. American effects of d–fenfluramine, which is thought to sup- Journal of Public Health, 82, 799–803. press appetite by releasing serotonin, on weight JEFFERY, R.W., ET AL (1997). Smoking–specific weight gain during cessation suggested that d– gain concerns and smoking cessation in a working fenfluramine did control weight over a placebo. population. Health Psychology, 16, 487–489. Serious medical complications that accompany d– JORENBY, D.E., ET AL (1999). A controlled trial of sus- fenfluramine, at least when used in combination tained–release bupropion, a nicotine patch, or both with phertermine, however, have diminished en- for smoking cessation. New England Journal of Medi- thusiasm for this drug. A study using phe- cine, 340, 685–691. nylpropanolamine, an over–the–counter weight MARCUS, B.H., ET AL(1999). The efficacy of exercise as an control drug, indicated that phenylpropanolamine aid for smoking cessation in women. Archives of Inter- users gained less weight and had higher quit rates nal Medicine, 159, 1229–1234. over a placebo group and a no treatment control NIDES, M.A., ET AL (1994). Weight gain as a function of group. A study of bupropion (Zyban) and weight smoking cessation and 2–mg nicotine gum use among gain indicated that weight gain was suppressed middle–aged smokers with mild lung impairment in while on the drug, but the effect disappeared when the first 2 years of the Lung Health Study. Health the drug was discontinued. Psychology, 13, 354–361. PERKINS, K.A. (1993). Weight gain following smoking SUMMARY cessation. Journal of Consulting & Clinical Psychol- Smoking cessation is likely to result in some ogy, 61, 768–777. weight gain, with women gaining more weight than PIRIE, P.L., ET AL (1992). Smoking cessation in women men. Both women and men express concern about concerned about weight. American Journal of Public gaining weight when quitting smoking; however, Health, 82, 1238–1243. fewstudies have found a relationship between U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. weight concerns and successful smoking cessation. (1990). The health benefits of smoking cessation. A Similarly, actual weight gain during cessation does report of the surgeon general. U.S. Department of not appear to predict relapse. Dietary programs Health and Human Services, Public Health Service, seem to be ineffective in controlling weight gain Centers for Disease Control, Center for Chronic Dis- during cessation, while exercise programs seem to ease Prevention and Health Promotion, Office on have some benefit. Pharmacologic agents appear to Smoking and Health. DHHS Publication No. be successful in delaying weight gain during cessa- (CDC)90–8416. tion; however, after withdrawal from the drug, any BETI THOMPSON significant effect on weight gain disappears. REVISED BY SCOTT J. LEISCHOW

BIBLIOGRAPHY

BORRELLI, B., ET AL (1999). Weight suppression and TOLERANCE See Addiction: Concepts and weight rebound in ex–smokers treated with ﬂuoxe- Deﬁnitions; Tolerance and Physical Dependence TOLERANCE AND PHYSICAL DEPENDENCE 1109

TOLUENE See Inhalants strains it. If there is tolerance to the rewarding or aversive effects of drugs, it is clear howtolerance might determine drug use. A reduction in the re- TOLERANCE AND PHYSICAL DEPEN- warding effectiveness of a given dose would require DENCE Tolerance and physical dependence are an increased dose to obtain the same degree of common consequences of drug self-administration. reward. Similarly, tolerance to aversive effects of a For those interested in understanding and modify- drug might mean a much larger dose could be ing alcohol and drug abuse and the problems they taken before the restraining aversive effect oc- cause, the greatest importance of tolerance and curred. physical dependence is in the contribution they There is remarkably little scientific evidence for make as determinants of drug self-administration. the common viewthat tolerance to the rewarding Some alcoholics, for example, can appear normal at effects occurs. The common and plausible viewthat BLOOD ALCOHOL CONCENTRATIONS (BAC) that tolerance results in a loss of rewarding effectiveness would prostrate most social drinkers. What role, if is based mainly on anecdotal evidence. In contrast, any, does tolerance play in paving the way to an there is ample scientific evidence of substantial escalation in drug use and in the medical and psy- tolerance to drug effects that could be viewed as chological problems caused by heavy drug use? In restraints on the motivation to self-administer. addition to being highly tolerant, alcoholics will Physical dependence as a promoter of self-ad- also be physically dependent on alcohol. What evi- ministration can be dealt with briefly. The earliest dence is there to support the common assumption theories of dependence assumed that the avoidance that physical dependence is a critical factor in of withdrawal was the most compelling motivation maintaining drug self-administration? for persistent drug use. The experimental evidence Such questions are best answered in the context for this viewis strongest in the case of opiates, but of a general theory of howdrug consumption is weak to nonexistent for other drugs, including alco- regulated. A useful starting point is the proposition hol. that behavior is motivated by its consequences. Tolerance can be characterized as a facilitator of Where tolerance is concerned, the important conse- consumption and its consequences, independent of quences of drugs are only those that depend on the underlying reasons for drug use. If a person is pharmacological effects. The pharmacological con- able to drink a lot more before becoming sleepy or sequences that determine self-administration can dizzy the capacity to drink is increased regardless be grouped according to whether they promote or of the reason for drinking. If the ability of tissue to restrain drug use. Rewarding consequences are resist damage does not increase with the body’s those that increase the likelihood of drug use. capacity to resist the drug effects that regulate con- Drugs may make a person feel alert, powerful, consumption, tolerance becomes an important deter- fident, relaxed, friendly, sexy, or talkative. They minant of medical and other problems. may alleviate ANXIETY,DEPRESSION, and physical As the twenty-first century begins, concepts of PAIN. All these consequences and more have been addictive disorders has focussed more on the com- hypothesized and evaluated as promoters of drug pulsive and relapsing drug-taking behaviors than use. on tolerance and physical dependence. To that end, People may initiate and maintain an episode of medications have been sought and used in the reha- drug use in the pursuit of rewarding consequences, bilitative process. Specific medications have been and they may end it because drugs also have aver- demonstrated to be helpful for psychiatric disor- sive pharmacological consequences at higher doses. ders coexisting with addiction. Some medications These effects should also be taken into account as showed promise in controlled studies in helping to restraints on self-administration. Many restraining rehabilitate patients dependent on nicotine, alco- consequences of drug use can be suggested, ranging hol, or opiates. from unwanted dysphoria (a state of unease) to frank physical illness. (SEE ALSO: Addiction: Concepts and Definitions; In summary, a simple regulatory theory asserts Causes of Substance Abuse; Research, Animal that ‘‘reward’’ drives drug use and ‘‘aversion’’ re- Model; Withdrawal ) 1110 TOPS

BIBLIOGRAPHY highly destructive behavior, did more harm than good. Instead, they permitted natural and logical CAPPELL, H. (1981). Tolerance to ethanol and treatment consequences to correct their daughter’s behavior of its abuse: Some fundamental issues. Addictive Be- while they sought emotional support from their haviors, 3, 197–204. friends. They wrote and published Toughlove CAPPELL, H., & LEBLANC, A. E. (1983). The relationship (1980) and founded an organization called the of tolerance and physical dependence to alcohol abuse Toughlove Support Network (which is described in and alcohol problems. In B. Kissin and H. Begleiter their later book, 1984). The network’s mission is to (Eds.), The biology of alcoholism. Vol. 7, The patho- promote what they view as a mode of intervention genesis of alcoholism: Biological factors. NewYork: for individuals, families, and communities. Plenum. According to the Toughlove philosophy, parents CAPPELL, H., & LEBLANC, A. E. (1981). Tolerance and are the ones with the dominant power in a family. physical dependence: Do they play a role in alcohol Children misbehave when parents fail to assert and drug self-administration? In Y. Israel et al. themselves or to take responsibility for their role as (Eds.), Research advances in alcohol and drug prob- parents, but when parents’ expectations are stated lems. NewYork: Plenum. clearly, a child will no longer control the family. O’BRIEN, C. P. (1996). Recent developments in the phar- Parents are urged to describe the behavior they macotherapy of substance abuse. (Special Section: expect from their children. Speculation about the The Contribution of Psychotherapy and Phar- causes of child misbehavior is discouraged. Parents macotherapy to National Health Mental Care). Jour- do not need to understand why their child misbe- nal of Consulting and Clinical Psychology, 64, 677. haves. Instead, they must act in coalition with other HOWARD D. CAPPELL parents to assert control of themselves and their REVISED BY MARY CARRLIN home environment. Toughlove parents are taught not to feel guilty about their child’s misbehavior, because children TOPS See Treatment Outcome Prospective are responsible for their own actions. A Toughlove Study parent of a destructive child might say: ‘‘We have had enough. We are not rescuing you from the trouble you have caused. We love you enough to say TOUGHLOVE The generic term toughlove no.’’ Proponents of Toughlove believe that drug (or tough love) describes a style of caring applied in and alcohol abuse is the most important causative diverse interpersonal contexts whereby one person factor in the disruptive behavior among teens. Once or group reasserts power over another for whom he parents suspect drug and alcohol abuse, it is impor- or she is responsible. Claire Kowalski was the first tant that they investigate by questioning their person to use the term in published material, in child’s friends, school officials, other family mem- 1976, to differentiate a respectful means of caring bers, and anyone else their child meets frequently. for elderly people that preserves self-mastery from When parents find drug and alcohol abuse, they a smothering style that promotes dependence. must require abstinence. Strict discipline and limit Since that first use, others have found the term setting are seen as the only means of enabling chil- useful. The Association of the Relatives and Friends dren to behave and to have a chance of regaining of the Mentally Ill endorses the concept (Roberts, control of their lives. 1985). In its most common use today, the term Parents must confront their child about the drug describes the means by which parents of abusive, and alcohol abuse and stipulate the behavior they delinquent, or drug-abusing children can regain expect. Toughlove recommends that they require parental control. Toughlove is also the name of a the child to stop using drugs and seek treatment if SELF-HELP program for these parents and their needed. If a child refuses to comply, he or she is to children. be ejected from the home. Many uncooperative Toughlove, the self-help program, was devel- children are sent to live with another Toughlove oped by Phyllis and David York in 1980. They family until they are serious about meeting their found that rescuing their daughter, who engaged in own parents’ stipulations. Children who refuse to TOXICITY 1111 live with another Toughlove family are out on their warned other parents to be cautious in disciplining own until they agree to their parents’ rules. their children. To gain help in maintaining firmness and setting Neither the Toughlove program nor the style of appropriate rules, parents attend a support group caring identified with it has been evaluated. On the consisting of other parents who endorse the one hand, there is anecdotal evidence from parents Toughlove principles. Toughlove support groups to vouch for it. On the other, as illustrated by the are organized by the parents without any profes- Hinckley family, Toughlove solutions can make sional leadership. Besides providing support for matters worse. At present, we do not know whether parents, Toughlove groups evaluate the effective- the positive or the negative is the more common ness of treatment programs and the effectiveness of outcome, or whether positive outcomes result from professionals who treat children for alcohol and factors having nothing to do with Toughlove. drug abuse. Hollihan and Riley (1987) used qualitative research methods to study a Toughlove parent group. (SEE ALSO: Adolescents and Drug Use; Parents They found that several themes characterized Movement; Prevention Movement) group sessions and defined the Toughlove program experience for parents. First, the lay-led group em- BIBLIOGRAPHY phasized that old-fashioned values are superior to those inherent in today’s method of raising chil- HOLLIHAN, T., & RILEY, P. (1987). The rhetorical power dren. Second, members regarded child-develop- of a compelling story: A critique of a ‘‘Toughlove’’ ment professionals as advocates for modern child- parental support group. Communication Quarterly, raising methods that blame parents for child mis- 35, 13–25. behavior. Third, they described the Toughlove KLUG, W. (1990). A preliminary investigation of group as their island of support within a pro-child Toughlove: Assertiveness and support in a parents’ social environment made up of the police, educa- self-help group. Paper presented at the Annual Con- tors, social workers, and the courts. Last, the group vention of the American Psychological Association, provided successful models of rule setting by par- Boston. ents and enforcement of strict discipline— KOWALSKI, C. (1976). Smother love vs. tough love. Social including as a final resort forcing a child to leave Work, 21, 319–321. home. The group presented a persuasive and com- LAWTON, M. (1982). Group psychotherapy with alcohol- forting rationale for the use of strict discipline that ics: Special techniques. Journal of Studies on Alcohol, addressed the needs of parents who were experienc- 43, 1276–1278. ing great stress and feelings of failure (Hollihan & NEMY, E. (1982). For problem teenagers: love, tough- Riley, 1987). Toughlove has been criticized as being simplistic ness. New York Times, April 26, p. B12. and heavy-handed. According to Hollihan and ROBERTS, A. (1985). A.R.A.F.M.I.: Association of the Riley (1987), parents in the group they observed Relatives and Friends of the Mentally Ill. Mental who did not believe their child was abusing drugs Health in Australia, 1, 37–39. or alcohol were nevertheless instructed in how to WOHL, L. (1982). The parent training game—from document such abuse. Other possible causes of Toughlove to perfect manners. Ms., May, pp. 40–44. their child’s misbehavior were ignored, because the YORK, P., & YORK, D. (1980). Toughlove. Sellersville, Toughlove solution is supposed to apply in all situ- PA: Community Service Foundation. ations. The tactic of throwing an unruly child out of YORK, P., YORK,D.,&WACHTEL, T. (1984). Toughlove the house is especially controversial. Although most solutions. Garden City, NY: Doubleday. children go to live with other Toughlove families, GREGORY W. BROCK some are forced to leave with nowhere to go and ELLEN BURKE can become homeless, a predator or a victim, or a threat to themselves and others. For example, John Hinckley, who attempted to kill President Ronald W. Reagan in 1982, had been cast out of his home TOXICITY See Complications; Poison Con- by parents who endorsed Toughlove and who later trol Centers, Appendix I, Volume 4 1112 TRANQUILIZERS

TRANQUILIZERS See Benzodiazepines cultivation led to increased coca cultivation and cocaine production in Colombia. In 2000, the U.S. Congress approved $1.3 billion of emergency aid to TRANSIT COUNTRIES FOR ILLICIT Colombia to help fight the increasingly powerful DRUGS Transit countries are those through drug trafficking organizations. U.S. military assis- which drug shipments travel to reach local dealers tance and equipment has also flowed into Colom- and users. Drugs that come to the United States bia. As more success was achieved against cocaine from South America pass through a six million source countries in the 1990s, and as pressure built square-mile transit zone that is approximately the against trafficking through Mexico and the Baha- size of the continental United States. This zone mas, drug traffickers dispersed their growing and includes the Gulf of Mexico, the Caribbean, and the processing operations and developed newsmugg- eastern Pacific Ocean. U.S. strategy to deal with the ling routes, many in the Caribbean. cocaine problem, for example, might best be described as a series of concentric circles around the source and trafficking countries of the Andes, INTERMEDIATE COUNTRIES through (1) the surrounding countries in South The intermediate transit countries in the Carib- America (2) the transit countries of MEXICO, Cen- tral America, and the Caribbean, to (3) the major bean and South America have played an increasing consumer countries. Since the 1990s, the United important part in drug trafficking, as opportunities States has similar objectives for dealing with both for drug interdiction are more difficult. The small source and transit countries—namely, to Caribbean states lack resources to perform ade- strengthen their governments’ political will and ca- quate lawenforcement; air drops of drugs to wait- pability; to increase their effectiveness in terms of ing boats have become common, because no Carib- military and law-enforcement activities; and to bean nation has a marine or security force capable help inflict significant damage on drug-trafficking of completely controlling territorial waters. How- organizations. ever, operations by the U.S., Jamaica and the Baha- Since 1990, the U.S. government has developed mas in the late 1990s led to a decline in cocaine detailed implementation plans for expanded drug- trafficking, while drug trafficking increased in control activities on a regional and country-specific Haiti, the Dominican Republic, and Puerto Rico. basis. The strategy emphasizes the major choke Stopping the flowof drugs in these transit coun- points at either end of the international chain: The tries goes beyond intercepting drug shipments at three source countries of COLOMBIA, Peru, and sea or in the air. Countries must deny traffickers BOLIVIA at one end and the primary transit countries of Mexico, the Bahamas, Jamaica, and Cuba at safe haven and prevent the corruption of political the other end. In addition to the source countries, institutions. Moreover, the financial systems in only Ecuador, Venezuela, and Brazil in South these countries must not be used to launder drug America have the potential for profitable cultiva- profits. The U.S. government has helped Caribbean tion of COCA leaf, but the U.S. government believes and Central American countries implement drug that only small-scale cultivation and involvement control policies that include the strengthening of in drug-transit activities exist in these countries. lawenforcement and judicial institutions, the mod- Consequently, only modest drug-control assistance ernization of laws, the strengthening of anti-cor- has been made available to them—largely in the ruption measures, and the operation of joint inform of training, technical assistance, and com- terdiction efforts. modities—to encourage them to take their own ac- The key to successful drug control in the sur- tions against high-value elements, such as money rounding and transit countries lies in U.S. ability to flows and essential and precursor chemicals. Brazil develop and use effective intelligence networks. and Venezuela, for example, manufacture essential The U.S. Department of Defense uses its intelli- chemicals used in COCAINE production. gence resources, including powerful communica- The success in the late 1990s of efforts by the governments of Bolivia and Peru to reduce coca tions equipment, to assist in the interdiction effort. TREATMENT ALTERNATIVES TO STREET CRIME (TASC) 1113

STRATEGY SUCCESS TREATMENT ALTERNATIVES TO STREET CRIME (TASC) This is a program The success of the U.S. strategy for potential designed to divert drug-involved offenders into ap- source and transit countries is predicated on build- propriate community-based treatment programs ing long-term institutions in these countries that by linking the legal sanctions of the criminal-justice work with the United States. However, the political system to treatment for drug problems. The pro- destabilization of Colombia in the late 1990s is a gram nowserves as a court diversion mechanism or potent reminder that policies can produce un- as a supplement to probation or other justice-sys- intended consequences; the success of Bolivia and tem sanctions and procedures. Created by Presi- Peru in reducing coca cultivation triggered changes dent Richard M. Nixon’s SPECIAL ACTION OFFICE in Colombia that dwarf the problems of the previ- FOR DRUG ABUSE PREVENTION (SAODAP) and ous decade. funded by the LawEnforcement Assistance Ad- To be successful, U.S. agencies must expand ministration (LEAA) and the National Institute of their efforts in the Pacific and the Caribbean to Mental Health (NIMH), TASC was an attempt to (1) collect and process intelligence; (2) help the find a way to break the relationship between drug transit countries develop their own intelligence col- use and crimes committed to support the cost of lection, sharing, and dissemination capabilities; obtaining illegal drugs. The idea for the initial (3) help these countries take action on their own to TASC programs derived from an analysis of the apprehend traffickers and seize drug shipments; criminal-justice system indicating that many drug- and (4) direct bilateral and multilateral efforts addicted arrestees were released on bail while against drug trafficking MONEY LAUNDERING, asset awaiting trial and were likely to continue to commit forfeiture, chemical diversion, and drug shipments. crimes. Although there were provisions for supervi- However, critics point out that the drug supply can sion of drug-dependent offenders after conviction (on probation) or after release from prison (pa- never be stopped and that interdiction efforts are role), no such mechanisms were in place to provide largely a waste of money. They argue for demand- supervision of those awaiting trial. Yet, if arrestees reduction programs in the U.S. However, U.S. pol- could be directed to treatment, success in treatment icy remains firmly committed to reducing the pas- could be taken into consideration at time of trial. sage of drugs through transit countries. The first TASC programs, in Wilmington, Dela- ware, and Philadelphia, Pennsylvania, became op- (SEE ALSO: Crop Control Policies; Drug In- erational in 1972. TASC currently operates in more terdiction; International Drug Supply Systems; than 100 jurisdictions in 28 of the U.S. states and U.S. Government) territories. In the mid-1990s, TASC programs received support from the U.S. Department of Justice BIBLIOGRAPHY through the Bureau of Justice Assistance (BJA) Criminal Justice Block Grants to state and local BUREAU OF INTERNATIONAL NARCOTICS MATTERS, U.S. DE- governments. LEAA was discontinued in 1982. PARTMENT OF STATE. (1992). International narcotics Many TASC programs have expanded their base of control strategy report (INCSR). Washington, DC: support so that state and federal funding is supple- Author. mented by private donations and grants or client WHITE HOUSE OFFICE OF NATIONAL DRUG CONTROL POL- fees. ICY. (2000). National drug control strategy: 2000 an- TASC programs initially focused on pretrial di- nual report. Washington, D.C. version of first offenders. The original TASC model was structured around three goals: (1) eliminating JAMES VAN WERT or reducing the drug use and criminal behavior of REVISED BY FREDERICK K. GRITTNER drug-using offenders; (2) shifting offenders from a system based on deterrence and punishment to one that, in addition, fostered treatment and rehabilita- TREASURY, U.S. DEPARTMENT OF tion; and (3) diverting drug-involved offenders to See U.S. Government: Agencies in Drug LawEn- community-based facilities so as to limit criminal forcement and Supply Control labeling and also to avoid the learning of criminal 1114 TREATMENT ALTERNATIVES TO STREET CRIME (TASC) behavior that occurs in prisons. These goals were a wide variety of participants in TASC programs. based on the assumption that treatment interven- Illinois TASC, for example, founded in 1976 by tion had a better chance of success with first-of- Melody Heaps, uses the name Treatment Alterna- fenders, since they had not yet been labeled as tives for Special Clients (TASC, Inc.) in order to criminals. It also reflected community concerns better describe the scope of its programs. The pro- that serious or dangerous offenders who might oth- gram provides case management and a comprehen- erwise be incarcerated would instead be released. sive array of services throughout Illinois for men, In practice, it turned out that most first-time drug women, and adolescents who have a variety of so- arrests were not necessarily first arrests, so the pro- cial, welfare, and health-related needs. Populations gram was quickly expanded to reach all drug-in- served include youth in the child-welfare system, volved offenders that the courts were willing to AIDS-affected clients, DUI (drunk-driving) of- divert into treatment. fenders, juvenile offenders, students, welfare recip- TASC procedures determine a drug-dependent ients, offenders sentenced to home confinement, offender’s eligibility for intervention, and they in- youth in community-based programs and those in clude assessment of the offender’s risk to the com- the child-welfare system, Supplemental Security munity, severity of drug dependence, and appro- Income (SSI) recipients, pretrial arrestees, and priateness for treatment placement. After an Cook County Jail inmates. For each special popula- individual is referred to a treatment program, tion targeted and served, appropriate interventions TASC case-managment services monitor that indi- and services have been devised, such as a school vidual’s compliance with the conditions of the intervention program, a gang intervention pro- treatment and rehabilitation regime, including gram, and youth services for substance-abusing expectations for abstinence, employment, and im- students and adolescents. Adult criminal-justice proved personal and social functioning. Progress is services include monitoring of offenders in home reported to the referring justice-system agency. Cli- confinement using technologies such as electronic ents who violate the conditions of their justice man- monitoring and drug testing; a jail project pro- date—TASC ‘‘contract’’ (or treatment agree- viding screening and assessment, orientation, in- ment)—are usually returned to the justice system, tensive therapeutic-community counseling, transi- where the legal process interrupted by TASC diver- tion counseling, and aftercare planning and sion goes forward. Specific ‘‘critical program elements’’ define the management. Illinois TASC is the sole agency pro- parameters of a well-described national TASC viding substance-abuse assessment and recommen- model. These have been carefully worked out by dations for the Illinois courts. As well as providing The National Consortium of TASC Programs offender case-management services, it offers train- (NCTP) (444 North Capitol Street, NW, Suite 642, ing for judges, state attorneys, public defenders, Washington, DC 20001; Phone: 202/783-6868; criminal-justice planners, and federal and state FAX: 202/783-2704). These critical elements pro- probation and parole staffs. vide the structure for the linkages between the TASC programs play an important role in re- criminal-justice and treatment systems. This model ducing the growing rates of drug-related street makes it possible to easily replicate TASC pro- crime and alleviating court backlogs. They have grams anywhere in the United States, including ur- been effective in identifying drug-involved of- ban, suburban or rural settings, and is easily adapt- fenders in need of treatment, assessing the nature able to specific population needs. NCTP provides and extent of their drug use and their specific treat- technical assistance for implementation of the ment needs, and referring them to treatment. TASC model program, training for program development, clients have been found to remain in treatment systems coordination, program assessment, devel- longer and so have better posttreatment success. In opment and dissemination of materials (such as addition, as an adjunct to parole and work release, model policies, procedures, protocols, etc.), train- the programs have the potential to help ease prison ing in the use of the ‘‘critical elements,’’ intern- overcrowding. TASC also effectively fulfills its orig- ships, and accreditation of TASC programs. inal purpose of linking the criminal-justice and Many of the states have expanded the TASC treatment systems by providing client identification model to provide a wide array of adjunct services to and monitoring services for the courts, probation TREATMENT FUNDING AND SERVICE DELIVERY 1115 departments, and other segments of the criminal- residential facilities. Only 2 percent were hospital justice system. inpatients. The cost of treatment varied greatly depending (SEE ALSO: California Civil Commitment Program; on setting. In the early 1990s, hospital inpatient Civil Commitment; Coerced Treatment for Sub- care was the most expensive on a daily basis stance Offenders; Crime and Drugs; Narcotic Ad- ($300–600/day), but it was usually of short dura- dict Rehabilitation Act) tion (30 days or less). Treatment in nonhospital residential programs was less expensive ($50–60/ BIBLIOGRAPHY day), but it commonly lasted longer (a fewmonths to 2 years). Programs that did not require the indi- INCIARDI, J. A., & MCBRIDE, D.C. (1991), Treatment al- vidual to live in a specialized facility were the least ternatives to street crime: History, experiences, and expensive, both on a daily basis ($5–15/day) and issues. DHHS Publication no. (ADM) 91-1749. Rock- over a full course of treatment. ville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, PRIVATE HEALTH INSURANCE and Mental Health Administration, National Institute on Drug Abuse. The availability of private health-insurance cov- MORGAN, J. (1992). Treatment alternatives to street erage for substance-abuse treatment grewin the crime. State ADM Reports no. 15 (June), Intergovern- 1980s. By 1990, better than 90 percent of health- mental Health Policy Project. Washington, DC: insurance plans had explicit coverage for drug George Washington University. treatment. Individuals with such private insurance JEROME H. JAFFE have a greater range of treatment providers from FAITH K. JAFFE which to choose than those who are indigent and have only government-funded programs at their disposal. Programs that mainly rely on insurance TREATMENT See Treatment; Treatment reimbursement, however, tend to be more expen- Types sive than those that receive the bulk of their support from government sources.

TREATMENT CENTERS DIRECTORY U.S. GOVERNMENT FINANCING See Appendix, Volume 4 In the U.S. general health-care system, 68 percent of the cost of services is borne by the individual, insurance company, or other private third- TREATMENT FUNDING AND SERVICE party payer. For substance-abuse or mental-health DELIVERY No single accepted method or set- care, in contrast, the government supplies 63 per- ting exists for the treatment of substance abuse— cent of the funds for substance-abuse treatment. alcohol and other drug-abuse disorders. Treatment After the private sector, which provides 37 percent is offered in specialty units of general and psychiat- of the funds, the states traditionally have been the ric hospitals, residential facilities, halfway houses, major source of treatment support (31%), followed outpatient clinics, mental-health centers, jails and by the federal government (24%), and then county prisons, and the offices of private practitioners. and local agencies (8%). States often finance treat- In the United States during the 1970s and ment by reimbursing providers through public- 1980s, drug abusers were commonly treated in welfare programs or through grants or contracts. programs distinct from those serving alcoholics. By Some states transfer funds to county and local gov- the 1990s, the two treatment systems were merged; ernments, which, in turn, purchase services from in 1991, of the estimated 11,000 substance-abuse providers. Another financing mechanism is Med- treatment programs in the United States, 79 per- icaid, a combined state and federal program that cent reported that they served both drug and alco- pays medical bills for low-income persons. Under hol abusers. Some 88 percent were enrolled in out- Medicaid, states can pay for substance-abuse care patient programs. Another 10 percent were in in inpatient general hospitals, clinics, outpatient 1116 TREATMENT, HISTORY OF, IN THE UNITED STATES hospital and rehabilitation services, and in group understanding of howa ‘‘disease’’ or ‘‘disorder’’ homes with sixteen or fewer beds. could overrule the capacity to choose. A federal program that pays the health-care This assumption is historically incorrect. First, it costs of persons 65 years of age or older, or those neglects the coexistence and mutual influence of who are disabled, is Medicare. This primarily views emphasizing free will or social or biological covers inpatient hospital treatment of alcohol or determinism. While one viewmay have enjoyed drug abuse, as well as some medically necessary greater influence at a given time, its competitors services in outpatient settings. The primary federal have never been vanquished. No generation has mechanism for paying for alcohol and drug treat- any more solved the puzzle of addiction than it has ment is the Substance Abuse Block Grant, admin- resolved the related enigmas of the relationship be- istered by the Department of Health and Human tween mind and body, choice and compulsion. Sec- Services. Funds from the block grant are distrib- ond, it is equally incorrect to associate condemna- uted to the states (and territories) using a formula tion and neglect with the free-will position or that takes the characteristics of the state’s popula- kindness and activism with the determinist per- tion into account. In fiscal year 1994, Congress spective. The truth is more complicated. appropriated approximately 1.3 billion dollars for As various studies have demonstrated, there is a the Substance Abuse Block Grant. The federal tenacious American folk wisdom about addiction. government also makes grants to individual treat- Simply put, it goes as follows: While addicts experiment providers to support innovative treatment ence a compulsion to take a drug, this develops as approaches, improve the quality of treatment, or the result of repeated bad choices that are socially to ensure services for underserved or special influenced; further, addicts can rid themselves of populations. compulsion only by developing self-discipline, perhaps with some skilled influence in the form of (SEE ALSO: Treatment; U.S. Government Agencies) treatment. Thus, in our culture, and despite the modern message that ‘‘addiction is a disease like hypertension or diabetes,’’ addicts are understood BIBLIOGRAPHY to be both sick and immoral, blameless and HEALTH INSURANCE ASSOCIATION OF AMERICA. (1991). culpable, free and determined. In the popular Source book of health insurance data. Washington, mind, and among treatment professionals, addicts D.C.: Author. are ambiguous characters. INSTITUTE OF MEDICINE. (1991). Treating drug problems, The history of treatment in the United States vol. 1. Washington, D.C.: National Academy Press. reflects this cultural dilemma. Cultures limit the INSTITUTE OF MEDICINE. (1990). Broadening the base of range of possible responses to a problem, and be- treatment for alcohol problems. Washington, D.C.: cause they tend to change very slowly in fundamen- National Academy Press. tal ways, to the extent that an important problem SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES recurs or remains unsolved, the range of possible ADMINISTRATION. (1992). Highlights from the 1991 responses will be explored repeatedly as new gener- National Drug and Alcoholism Treatment Unit Sur- ations search for fresh insights and effective meth- vey (NDATUS). Rockville, MD: Author. ods of intervention. At various times, treatment has SALVATORE DI MENZA embraced exhortation and coercion, sermons and miracle drugs, democratic mutual aid, and auto- cratic professional prerogative—often simultaneously. TREATMENT, HISTORY OF, IN THE UNITED STATES The history of the treatment THE PREMODERN ERA of alcohol and other drug problems is often assumed to be a straightforward story of progress— Modernity has different meanings with respect moralism, neglect, and brutality were displaced by to the treatment of habitual drunkenness and drug scientific knowledge, medical activism, and profes- addiction. In the case of habitual drunkenness, the sional civility; a viewthat the addict exercised free modern era is traceable to the birth of ALCOHOLICS will in choosing to use drugs was succeeded by an ANONYMOUS (AA) in 1935. In the case of drug TREATMENT, HISTORY OF, IN THE UNITED STATES 1117 addiction, delineating historic periods is more diffi- couched in terms of Christian charity, economic cult, but we will mark the modern era by the intro- self-improvement, and democratic principles. duction of methadone maintenance (for heroin de- The hallmark of mutual aid is the banding to- pendence) in 1965 and passage of the federal gether of people in similar circumstances to help NARCOTIC ADDICT REHABILITATION ACT (NARA) in one another. (The popular term ‘‘self-help’’ is thus 1966. misleading.) The Washingtonians and their succes- We should also clarify our choices of terminol- sors did not invent the methods by which they ogy. The terms alcoholism and alcoholic date from fostered solidarity and mutual support. However, the middle of the nineteenth century, but they did in adapting the voluntary association to the reform not come into common professional use until the of drunkards, the Washingtonians introduced new early twentieth century and were not embedded in elements. the American vernacular until after the rapid Owing its provenance to the revival meeting, the growth of AA during the 1940s. The more common most striking and controversial (some found it dis- professional terms in the premodern era were ine- tasteful) Washingtonian innovation was the confes- briety and inebriate, but as these often were used to sion of drunkards before their peers, and some- refer to a heterogeneous group nowcalled ‘‘sub- times before a general audience. We are familiar stance abusers,’’ we will use the durable term with its contemporary form: ‘‘I am Jim B, and I am drunkard when writing about this era. Similarly, an [alcoholic, drug addict, etc.]’’; but the practice the term drug addict was not in common use until dates from Washingtonian ‘‘experience lectures,’’ the early 1900s; before this time habitual users of forums for the telling of ‘‘drunkard’s tales,’’ stories drugs were known as ‘‘morphinists,’’ ‘‘cocainists,’’ of degradation, struggle, and redemption through or sometimes, ‘‘dope fiends.’’ In order to speak gen- sobriety. These introduced the drunkard’s tortured erally and to avoid pejorative (if historically accu- inner life to the polite public. ‘‘You all knowme rate) terminology, we will use drug addict, and we and what I used to be,’’ Salvation Army lecturers will use addict and addiction when speaking of often began. both habitual drunkards and drug addicts. Some Washingtonian societies also established temporary homes, or refuges, for drunkards. These THE TREATMENT OF were places where drunkards could live for a short time while they sobered up and were introduced to HABITUAL DRUNKARDS the Washingtonian fellowship, whose members The Tradition of Mutual Aid. The organized, found them jobs and other necessities. A century specialized effort to help habitual drunkards began later, AA would reinvent this institution (the recov- with the Washington Total Abstinence Movement ery home) as part of its twelfth-step work—the in 1842. This Washingtonian Movement stands at commitment to help other drunks. the head of a tradition of mutual aid that developed Although not continuous with these early ref- throughout the 1800s in close connection to Ameri- uges, beginning in Boston (1857), San Francisco can Protestantism, particularly its evangelical ex- (1859), and Chicago (1863), a number of formal pressions. The Salvation Army, which traces its inebriate homes were established to treat drunk- American incarnation to the mid-1870s, is also in ards in the Washingtonian tradition. Typically, this line, and so is AA and the many other ‘‘Anony- these were small institutions (fewer than 50 beds), mous’’ fellowships it inspired. operated as private charities, sometimes under reli- Washingtonian societies were dedicated to so- gious or temperance auspices. They relied on the bering up hard drinkers, usually (but not always) voluntary cooperation of their residents and used men. The societies intended to foster a solidarity temperance fellowship as a form of what we now based on shared experience with suffering that call aftercare. They were located in urban environ- transcended profound social divisions. (They were ments and did not isolate their residents from com- neutral on the divisive question of prohibition.) munity life. Although they often were su- Although some famous teetotalers like Abraham perintended by physicians, residence rarely Lincoln were members, the societies included the exceeded three weeks and medical treatment was disreputable, the unlettered, and sometimes non- considered important only in managing withdrawal whites and women as equals. Their motives were symptoms or DELIRIUM TREMENS (DTs). The terms 1118 TREATMENT, HISTORY OF, IN THE UNITED STATES disease and ‘‘vice,’’ cure and ‘‘reformation’’ were Although the Washingtonian Movement as such used interchangeably, and sober outcomes were was defunct by 1850, Washingtonianism was ex- attributed to the influences of family, friends, and tremely influential until about 1865. The tradition the fellowship, not to medical intervention. Ine- did not disappear, but in the decades following the briate homes practiced a profoundly social (and Civil War (1861–1865), profound changes in sometimes spiritual) form of treatment based on American culture and society, and related changes the belief that the human capacity for transforma- in the temperance movement, blunted Washingto- tion was never extinguished, no matter how ‘‘des- nian influence and gave newprominence to a com- potic’’ the ‘‘appetite’’ for alcohol. peting philosophy of treatment and its attendant For those in the Washingtonian line, the source practices and institutional embodiment. The phi- of such optimism was their belief in the presence of losophy was that of biological determinism, or ‘‘so- an immortal God in the human mind. The mind, maticism,’’ and its institutional expression was the they believed, was distinct from the brain and other ‘‘inebriate asylum.’’ corruptible flesh and was formed in God’s image. The Asylum Tradition. In 1810, Benjamin By the mid-1800s, the image of God was far more Rush, a Philadelphia physician, signer of the Decla- benign and rational than the often wrathful, finally ration of Independence, and first formulator of a inscrutable deity of even the early 1700s. This disease theory of addiction (though not the inven- gradual change in the conception of God owed tor of the idea), proposed ‘‘sober houses’’ for much to the spread of the market as arbiter of drunkards. However, Samuel Woodward, a Massa- economic affairs and social relations. The rigorous chusetts insane asylum superintendent and tem- logic of the market reordered economics from the perance orator was the father of institutional treatment based on a somatic explanation of habitual academy to the workshop. In its train, a disci- drunkenness. In a tract written in 1835, Woodward plined, optimistic rationalism—and the ideas of contributed two critical ideas to what would be- moral progress and human perfectibility—suffused come the inebriate asylum movement of the nine- popular culture and theology. teenth and early twentieth centuries. The first was At the same time, another form of rationalism, that drunkards could not be treated successfully on that of natural science, was pervading popular dis- a voluntary basis. The second, which flowed from course and causing tumult in seminary and pulpit. the first, was that they needed legal restraint in a Science did not overthrowreligion so much as as- ‘‘well-conducted institution’’—by which Wood- sume a place alongside it. For believers, scientific ward meant something like the insane asylum that order was a wonder of the divine plan. The natural he superintended. ‘‘laws of health,’’ as various rules of disciplined The line of thinking staked out by Rush and self-denial were known, were signals of divine in- Woodward had no institutional realization until an tent, of God’s ideas about right living. The drunk- inebriate asylum subsidized by the State of New ard was therefore both sinful and sick, having con- York opened in Binghamton in 1864. Another was tracted the disease as the result of moral opened in Kings County, NewYork, in 1869. In transgression. (A common analogy of the time was subsequent decades, pursuant to arduous promo- to syphilis; today, some religious leaders speak sim- tion by the American Association for the Cure of ilarly of AIDS.) Thus, while Washingtonians and Inebriates (AACI, founded in 1870), public ine- their successors spoke of addiction as a disease—by briate asylums opened in Massachusetts (1893), which they meant an organically based compul- Iowa (1904), and Minnesota (1908). Other juris- sion—they also employed clerical images, for they dictions chartered inebriate asylums but never built believed in the power of the divinely inspirited hu- them (Texas and Washington, D.C.), and in Cali- man mind to choose the rational good (total absti- fornia an inebriate asylum chartered in 1888 was nence from alcohol) and to thus achieve health. In converted to an insane asylum before the facility the Washingtonian tradition, the languages of mo- opened in 1893. Indeed, Binghamton was con- rality and disease became assimilated, and remain verted to an insane asylum in 1879. By the advent so in the many contemporary Anonymous fellow- of Prohibition in the United States in 1920, all ships’ claim that addiction is in part a ‘‘spiritual public inebriate asylums had been closed or con- disease.’’ verted to other use. TREATMENT, HISTORY OF, IN THE UNITED STATES 1119

The inebriate-asylum movement spawned doz- ular among forward thinkers. In the most widely ens of private sanitaria that treated well-to-do read book of its time, the utopian novel, Looking drunkards and, by the 1890s, drug addicts. How- Backward (1888) by Edward Bellamy, the author ever, judged by its manifestation in brick and characterized all sorts of misconduct as disease, mortar, the movement for public treatment was a and his near-perfect world of the year 2000 cured failure. For two related reasons, the AACI was no- its rare wayward citizens in public hospitals. tably unsuccessful in converting legislatures to its If Washingtonians assimilated the languages of cause. First, its physician members never could morality and disease, the rising generation of ine- produce a strictly medical ‘‘cure’’ for addiction. briate-asylum enthusiasts radically separated Although its theorist-practitioners developed rigor- them, and often reduced human volition to a ously somatic explanations of addiction that dis- by-product of neurology. In the United States and pensed with will power, spirituality, and the thera- Europe, they initiated research on the biology (and peutic necessity of fellowship, they relied on later, the genetics) of addiction. Primitive by to- recuperation by bed rest, a healthy diet, and thera- day’s standards, it nonetheless established a robust peutic baths (hydrotherapy), followed by the disci- tradition of inquiry that remains lively. pline of useful labor. This regime was highly struc- The inebriate-asylum movement appealed to tured (military analogies were popular) and American aspirations to create a better world medically supervised, and was set in a context of through science, but it also addressed growing fears prolonged legal restraint (involuntary commit- of social disorder. The extent of such disorder ment). However, there was nothing particularly in- should not be exaggerated, however; pre-industrial novative or medical about this approach. Its meth- America was more disorderly than nostalgic chron- ods already were the staples of lunatic asylums iclers have made it seem, and urbanization and (called mental hospitals in most states after about industrialization were less chaotic than critics 1900), almshouses, and county jails, institutions sometimes contend. On the whole, though, life after that managed huge numbers of habitual drunkards the Civil War was more complex, more anonymous, and, after the 1880s, drug addicts. Second, the and less certain. inebriate asylum was an ambitious undertaking: Immigration from abroad was an important fuel like the insane asylum, it was to accommodate for such change and promoted the (American) na- several hundred patients on a sequestered rural tivist fears that accompanied it. In the 1830s, free estate. Fewlegislatures could be persuaded that Americans were overwhelmingly Anglo-Saxon in such costly new institutions were worth the price. origin and Protestant in belief. By the 1880s, this In a word, the inebriate asylum was viewed as was changing dramatically. Burgeoning northern redundant. and western cities were becoming testing grounds The ideology of the inebriate-asylum move- for the promise and limits of diversity—indeed, for ment—its adherents’ view of the world—was explanations of diversity. Amid glaring inequality shaped by two profound, contemporaneous devel- of wealth and opportunity, cultural conflicts often opments in American culture and society: (1) the were played out around practices of consciousness rising esteem and secularism of science and (2) the alteration. Protestant, native-born Americans (in- growing disorder and complexity of American soci- cluding African Americans) were remarkably ab- ety after the Civil War. The movement reflected the stemious (a notable success of the Protestant- grand aspirations of Gilded Age science, whose driven temperance movement); the mostly Roman practical applications were transforming American Catholic Italians and French were daily wine drink- life: railroads and streetcars, the telephone, gas and ers; Poles, Germans, and some Scandinavians electrical lighting—all attested to the power of sci- drank large quantities of beer (some on Sunday— ence and human ingenuity. It was a time when in public beer gardens). ‘‘scientific’’ understanding became the basis for Of Irish Catholics, who had a large temperance professional standing, not only for medicine, but movement of their own but also a penchant for for all manner of professional groups, from proto- drunkenness (what is known as a ‘‘bi-modal distri- social workers to plumbers. The metaphor of dis- bution’’ of drinking habits), a California temper- ease, and the optimistic message implicit in its ance editor wrote in 1883: ‘‘They are by far the use—that all defects could be cured—became pop- worst and meanest material in which to store 1120 TREATMENT, HISTORY OF, IN THE UNITED STATES whisky.’’ Native Americans had been introduced to tion laws but also statutes that in a few states alcohol by traders and government agents from permitted the forced sterilization of addicts. colonial times, so ‘‘firewater’’ became a factor in In sum, the legacy of the inebriate-asylum the westward movement and the ensuing Indian movement was the biologically based approach to Wars. The ‘‘idolatrous’’ (non-Judeo-Christian) understanding addiction, the corollary claim that Chinese introduced opium smoking to America, a addiction is the special province of medicine and practice that crossed the color line during the physicians, the notion that successful treatment re- 1870s and became popular among young white quires legal coercion, and the assertion that treat- men and women during the 1880s. Then from ment is both a responsibility of government and a 1900 to 1920, Mexicans became associated with commodity to be sold on the market. These ideas Cannabis (MARIJUANA) use in the West and South- endure as part of the complex intellectual, profes- west. In the South, African-American men fre- sional, and political fabric of treatment. quently were accused of the riotous use of COCAINE, The Tradition of Mental Hygiene. The men- with subsequent designs on white women. tal hygiene movement, customarily dated from the The increasingly diverse backgrounds of the 1908 publication of Clifford Beers’ A Mind That U.S. population became a source of conflict and Found Itself, represented a departure from the so- disorder; the rollercoaster ride of industrial capital- matic tradition of thought about mental disorder ism was another. The United States experienced and addiction. At the same time, it did not appeal two prolonged economic depressions (then called to spiritual explanations nor did it dwell on will ‘‘panics’’) between the Civil War and the turn of power. Rather, mental hygienists employed a socio- the century— from 1873 to 1878 and from 1893 to biological determinism: Although addiction could be the result of hereditary biological defect, and 1898. In between, a short but sharp slump during could be incurable, its origins were mainly familial the mid-1880s took its toll on stability. During and social, and if the condition was addressed early these years, the noun ‘‘tramp’’ entered the Ameri- on, could be arrested. Mental hygienists stressed can language; the country experienced its first pro- the important roles of family, friends, and occupa- nounced labor violence and political bombings (dy- tion in creating a salubrious environment for an namite being an 1860s product of scientific addict’s continuing sobriety. Mental hygiene did ingenuity); in the spring of 1894, ‘‘armies of the not speak the language of mutual aid, but it was unemployed’’ converged on Washington, D.C., similarly environmental in outlook. This was the from all over the country. beginning of what later would be called community This era of mounting diversity and instability mental health, and its point of viewvirtually de- was marked by a failing faith in exhortation (verbal fines what we understand to be ‘‘modern’’ about appeal) as a method to achieve social regulation treatment and the biopsychosocial perspective. and by a concomitant exaltation of coercive means The environmentalism of mental hygiene chal- (force). Although never abandoning altogether its lenged the rationale of the asylum model of treat- sympathy for drunkards, the temperance movement. Mental hygienists criticized the asylum’s lack ment made securing prohibitionist measures its pri- of connection with community life and its reliance mary objective. Although never withdrawing its on involuntary treatment, claiming that only vol- support from surviving Washingtonian institutions, untary access to free or inexpensive care would temperance adherents simultaneously supported attract patients in the early stages of drinking or the more stringent regime promoted by inebriate drug-taking careers. The history of the Massachu- asylum enthusiasts, some of whom believed that an setts Hospital for Dipsomaniacs and Inebriates orderly, peaceful society required the lifetime de- (1893–1920) illustrates well the influence of men- tention of incurable addicts. Indeed, the temper- tal hygiene philosophy and practice. Between 1893 ance movement helped to popularize theories that and 1907, the hospital was run on the asylum purported to demonstrate a biological basis for the model. After a complete reorganization in 1908, it failure of certain racial and ethnic groups to live up followed a mental hygiene course: Most of its ad- to the abstemious standard of so-called native missions were legally voluntary; the hospital estab- stock—or to benefit from treatment. In the name of lished a statewide network of outpatient clinics; it ‘‘prevention,’’ such views justified not only prohibi- worked closely with local charities, probation of- TREATMENT, HISTORY OF, IN THE UNITED STATES 1121

fices, employers, and the families of patients. date there have been no suggestions that tobacco Known finally as Norfolk State Hospital, it was a addicts should be treated on a compulsory basis, preview of what treatment was to become, begin- although the places where it is legal to smoke have ning in the 1940s. been diminishing. Even so, Norfolk created on its campus a ‘‘farm’’ for the long-term detention of ‘‘incurables.’’ The THE TREATMENT OF DRUG ADDICTS mental hygiene movement modified the emphasis of the asylum tradition but did not entirely aban- Although the San Francisco Home for the Care don its practices. Indeed, under the banner of men- of the Inebriate (1859–1898) treated a fewopium tal hygiene, between 1910 and 1925, many local addicts as early as 1862, Washingtonian institu- governments across the United States established tions mainly treated drunkards. Similarly, al- ‘‘farms’’ to segregate repeated public drunkenness though a fewreborn drug addicts wereamong the offenders and drug addicts. Some of these persisted legions of the Salvation Army and other urban until the 1960s, and some have been reopened in missions by 1900, they were vastly outnumbered recent years to accommodate homeless people with by reformed drunkards. Until the organization of alcohol and drug problems. As discussed below, the what is today NARCOTICS ANONYMOUS (NA) in asylum tradition remained particularly important 1953, there was no large or well-defined group of in the treatment of drug addicts. addicts involved in the practices of mutual aid, and there were a variety of reasons for this. Drug addiction was not a matter of widespread TOBACCO concern until after the Washingtonian philosophy Although tobacco use is nowwidelyconsidered had been eclipsed by the asylum model of treat- in the United States to be a problem akin to drug ment. Further, drug addicts were quickly perceived dependence, for most of the twentieth century it to be more exotic and ominous than habitual was not treated as such by either the medical or drunkards. Although there were many people ad- criminal-justice establishment. However, nine- dicted to morphine as a result of ill-advised medical teenth-century temperance groups sawtobacco use treatment or attempts at self-treatment during the as another form of inebriety. As far back as the late 1800s, this more or less respectable population 1890s, advertisements for patent medicines declined after the turn of the century as physicians claimed to help people break the tobacco habit. In and pharmacists reformed their dispensing prac- the great temperance upsurge of the early twentieth tices and newlawsrequired the disclosure of the century, more than twenty states passed tobacco content of patent medicines and nostrums. At the prohibition laws, but most of these were quickly same time, a growing number of urban young peo- repealed. Public concern with habitual tobacco use ple began to experiment with drugs, especially declined dramatically from the 1920s through the smoking opium, morphine, and cocaine. By 1910, 1950s, and cigarette smoking (over smokeless to- drug addiction was popularly associated with petty bacco, pipes, or cigars) became normative behavior thieves, dissipated actors, gamblers, prostitutes, among men and grewsteadily among women.This and other nightlife aficionados, and with racial mi- situation changed abruptly with the publication of norities and dissolute youth. Unlike habitual the 1964 Report of the U.S. Surgeon General that drunkards, drug addicts never were caricatured as linked cigarette smoking to cancer. Since then, in- boisterous and occasionally obstreperous nuisances creasing attention has been paid to the tobacco or buffoons; especially after 1900, they usually habit, or TOBACCO DEPENDENCE, and to treatment were portrayed as dangerous predators and for it. Treatment approaches are at least as varied corrupters of society, alternating between drug-inas those described here for alcohol and other drugs. duced torpor (in the case of opiates) or hyperactiv- Pharmacological treatments, such as nicotine ity and hallucination (in the case of cocaine) and a chewing gum and skin patches, have been used, as craving that propelled them on relentless and un- have acupuncture, hypnosis, mutual aid, aversive scrupulous searches for drugs and the means to buy electric shock, and other techniques. While many them. people advocate that government or private insur- The ‘‘criminal taint’’ of drug addiction, and the ance should pay for treatment of this addiction, to widespread view that most addicts were incurable 1122 TREATMENT, HISTORY OF, IN THE UNITED STATES and would do anything to alleviate withdrawal symptoms, provided a powerful rationale for their prolonged confinement under strict conditions. Even the mental hygienists at Norfolk State Hospi- tal had no expectation that addicts would remain sober and favored incarcerating them in the Massa- chusetts State Farm at Bridgewater, a correctional facility. Indeed, state hospitals were generally more opposed to admitting addicts than habitual drunkards, preferring to have them incarcerated in jails. Even more than drunkards, addicts disturbed the routine and good order of state hospitals, in no small part because they were, as a group, considerably younger and less conventional than other hospital patients. They pursued sexual liaisons in vio- Nancy Reagan greets local youngsters who are lation of institutional rules against fraternization; members of the ‘‘Just Say No’’ club at the White they smuggled drugs into the hospitals; and once House, June 22, 1986. ( Bettmann/CORBIS) through withdrawal, they escaped in droves. Nor were jails and prisons anxious to take in Washington (1935) opened state-sponsored varia- addicts, mainly because of the problem of smugg- tions on the jail farm, though under the auspices of ling. By the late 1880s, opium was a customary their state hospital systems. (though illicit) medium of exchange at San Quentin The growing number of addict-prisoners in the Prison in California, and it was routinely available federal system also led to their segregation, first at in the big county jails of the United States at the Leavenworth, Kansas (mainly), and then at two turn of the century. As state laws against the sale or narcotic hospitals opened at Lexington, Kentucky possession of opiates and cocaine proliferated in the (1935) and Fort Worth, Texas (1938). Operated 1890s, and as they began to be more strictly by the U.S. Public Health Service, these hospitals worded and enforced after 1910, county jails and were in fact more like jails, although they were state prisons faced a major problem of internal authorized to admit voluntary patients of ‘‘good order. This intensified with the implementation of character’’ whose applications were approved by the federal HARRISON NARCOTICS ACT (passed in the U.S. Surgeon General. Initially, these patients 1914 to take effect in March 1915), particularly were kept involuntarily once they had been admit- after a U.S. Supreme Court decision in 1919 made ted, but a federal district court ruling in 1936 it illegal for physicians to prescribe opiates for the affirmed that voluntary patients could leave after purpose of maintaining an addict’s habit. The vast giving notice. Before they were closed in the 1970s, majority of drug offenders, even those arrested by the two facilities had admitted more than 60,000 federal agents, were prosecuted under state drug individuals comprising over 100,000 admissions. and vagrancy laws and sent to state and county Jailers were also an important part of local polit- lockups. The resulting crisis led jailers to support ical coalitions in support of a short-lived and con- two related treatment strategies. troversial treatment strategy of the early 1920s— The first of these was the creation of special drug dispensaries for registered addicts. At least institutions for drug addicts. Thus the county farms forty-four such clinics were established nationwide, mentioned earlier in this essay were created, or most in late 1919 or early 1920, following the laws were passed to allow addicts to be committed Supreme Court’s antimaintenance ruling. to existing state or county hospitals with wards In principle, these were not to be maintenance designated for this purpose. Mendocino State Hos- clinics. Addicts initially were to receive their cus- pital in California, Worcester State Hospital in tomary dosages of morphine (occasionally heroin, Massachusetts, Norwich State Hospital in Connect- and very rarely, smoking opium), and were then to icut, and Philadelphia General Hospital, to name a be ‘‘reduced’’ over a short time to whatever dosage few, treated significant numbers of addicts in the prevented withdrawal. At this point, abstinence 1910s and 1920s. Later, California (1928) and was to be achieved. TREATMENT, HISTORY OF, IN THE UNITED STATES 1123

In practice, few of the clinics worked this way. essentially in the asylum tradition, supplemented Many clinic operators believed that their primary by the mental hygiene innovation of supervised aim was to mitigate drug peddling by supplying probation. In 1961, California passed legislation addicts through medical channels. This implied a permitting the compulsory treatment of drug ad- maintenance strategy at odds with the Supreme dicts (including marijuana users) and established Court’s interpretation of the Harrison Act and with the California Civil Addict Program within the De- some earlier state laws forbidding maintenance (in partment of Corrections. From 1962 to 1964, more California and Massachusetts, e.g.). Further, most than 1,000 people were committed to a 7-year clinic operators agreed with the American Medical period of supervision, which typically involved an Association (AMA) that dispensaries could only initial year of residential treatment in a facility work effectively within the law if prolonged institu- surrounded by barbed wire to discourage prema- tional treatment was available once the addict’s ture departure. In 1964, NewYork passed similar dosage had been reduced to the brink of with- legislation but assigned its implementation to a drawal. In the absence of such institutional capac- special commission rather than to the Department ity, reduction was useless, and so clinic doctors of Corrections. As in California, NewYork’s resi- rarely bothered. The Prohibition Unit of the U.S. dential treatment facilities were ‘‘secure.’’ As late Department of the Treasury (which enforced the as 1966, the federal NARCOTIC ADDICT REHABILITA- Harrison Act), state boards of pharmacy (which TION ACT (NARA), in most respects a piece of typically enforced state drug laws), and local medi- ‘‘modern’’ legislation, nonetheless provided for the cal societies and lawenforcement agencies re- compulsory treatment of addicts and made the hos- garded the clinics as stop-gaps, valuable only until pitals at Lexington and Fort Worth into the institu- adequate public hospitals could be opened. tional bases of the NARA program. In the midst of the inflation following World War I, localities looked to the states to finance such insti- THE MODERN ERA tutions and states looked to the federal government, particularly the U.S. Public Health Service, The modern history of alcohol and drug treat- which had operated hospitals for merchant mari- ment has been shaped by the therapeutic pluralism ners since 1792. But legislation to create a federal descended from the mutual-aid, asylum, and men- treatment program failed to pass and the states tal hygiene traditions; the growing prestige of clini- were thrown on their own resources. The Prohibi- cal and basic medical research; the coexistence of tion Unit, convinced that the clinics were doing public and private sectors of treatment; and an more harm than good, moved to close them, threat- increasingly complex field of interorganizational ening dispensing physicians with prosecution. The relationships involving several layers of govern- clinics closed rapidly. The last one, at Shreveport, ment and substantial fragmentation within each Louisiana, closed in 1923. Addicts were consigned layer. to their customary ports of call in jails, prisons, or for the fortunate few, private sanitaria. ALCOHOLISM TREATMENT The controversy over maintenance did not disappear, however, particularly on the West Coast, The influence of ALCOHOLICS ANONYMOUS can where efforts to loosen its prohibition in the states hardly be exaggerated. Whatever its therapeutic of California and Washington continued until the success—a point of warm debate among scholars— United States entered World War II (1941). Fur- AA has profoundly affected the treatment of people ther, both federal and state governments permitted nowregularly knownas alcoholics. AA’s impact the maintenance of a small number of addicts, has been both ideological and institutional; that is, usually of middle age or older, suffering from se- its promotion of ‘‘disease theory’’ within the mu- vere pain related to a terminal illness or an incura- tual-aid tradition has changed howrecent genera- ble condition. However, the period from 1923 tions think about excessive or problem-causing al- through 1965 was generally characterized by the cohol consumption and treatment methods, and the strict enforcement of increasingly severe laws penetration of policymaking bodies and treatment against drug possession and sales, by relentless op- institutions by people recovering from alcoholism position to maintenance, and by treatment that was has shaped the funding and practices of treatment. 1124 TREATMENT, HISTORY OF, IN THE UNITED STATES

AA’s impact was facilitated by the growing in- legal and correctional system’s jurisdiction over al- fluence of the mental hygiene movement during the coholics; in addition, it provided a rationale for the 1920s and 1930s, for AA provided the critical ther- increased availability of services for alcoholics apeutic bridge between the segregating institution within established medical facilities and under the and the community at large. This was recognized aegis of public health. Jellinek was widely read in quickly by men like Clinton Duffy, the great ‘‘re- the literature of the earlier inebriate asylum move- form’’ warden of San Quentin, who encouraged the ment, and although he disparaged its science he establishment of AA groups in his prison in 1942. understood and sympathized with its aims. He fully Much early twelve-step work was done in U.S. understood that whatever its equivocal status as county jails. Harvard psychiatrist Robert Fleming scientific truth, the assertion that alcoholism is a opined in 1944 that the prolonged institutionaliza- disease carries important implications for treat- tion of alcoholics was no longer necessary; a week’s ment policies. medical care in a general hospital followed by com- Several important court decisions in the 1960s munity-based psychotherapy and AA participation endorsed the viewthat alcoholism wasa disease; in was his new prescription. The growth of AA per- 1967, a presidential commission on lawenforce- mitted the first substantial stirrings of community ment concluded that it was both ineffective and care since the Washingtonian Movement. inhumane to handle public drunkenness offenders During the early 1960s, some state hospitals, within the criminal-justice system and recom- particularly in Minnesota, incorporated recovering mended creating a network of detoxification cen- alcoholics and the principles of AA into their treat- ters instead. In 1970, Congress passed the Compre- ment programs. What became known as the Min- hensive Alcohol Abuse and Alcoholism Prevention, nesota model of short-term inpatient care (usually Treatment and Rehabilitation Act (the ‘‘Hughes 28 days) and subsequent AA fellowship and recov- Act’’). Senator Harold Hughes, a former governor ery-home living spread slowly but discernibly of Iowa, was a recovering alcoholic. A persuasive among private treatment providers such as the HA- speaker, Hughes became the conscience of the Con- ZELDEN Foundation, also in Minnesota, and the gress in developing support for a more humane and Mary Lind Foundation in Los Angeles. Across the decent response to people with alcoholism and re- country, local councils on alcoholism, dominated lated problems. He was supported in these efforts by people recovering from alcoholism and encour- by Senator Harrison Williams, Congressman Paul aged by the NATIONAL COUNCIL ON ALCOHOLISM Rogers, and several advocacy groups led by the AND DRUG DEPENDENCE and the National Institute National Council on Alcoholism and the North of Mental Health (NIMH, created in 1946, was an American Association on Alcohol Problems. While ardent promoter of community psychiatry), began Hughes’s early efforts had been supported by Presi- to press states and localities for outpatient clinics, dent Lyndon Johnson and Assistant to the Presi- diversion of alcoholics from jail, and other methods dent Joseph Califano, it was President Richard M. consistent with the traditions of mutual aid and Nixon who signed the legislation establishing the mental hygiene. Even so, treatment resources for NATIONAL INSTITUTE ON ALCOHOL ABUSE AND alcoholics did not expand dramatically. A survey in ALCOHOLISM (NIAAA). This legislation made fed- 1967 found only 130 outpatient clinics and only eral funds available for the first time specifically for 100 halfway houses and recovery homes dedicated alcoholism treatment programs. to serving alcoholics. Alcoholics continued to be The Hughes Act accomplished three goals of the barred from most hospital emergency rooms. modern alcoholism treatment movement. First, it All this advocacy and organizing activity were effectively redefined alcoholism as a primary disor- propelled by the concept of ‘‘alcoholism as a dis- der, not a symptom of mental illness. Second, and ease,’’ a proposition given its most systematic mod- based on this distinction, it created the federal ern exposition by E. M. Jellinek in The Disease agency— NIAAA—that would not be dominated Concept of Alcoholism (1960). Jellinek was more by the mental-health establishment competing for provisional in his use of the term than most of his the same resources. Finally, and of great practical readers appreciated, but he understood the impor- importance, the Hughes Act established two major tant strategic value of such a claim. In the first grant programs in support of treatment. One au- instance, the language of disease challenged the thorized NIAAA to make competitive awards TREATMENT, HISTORY OF, IN THE UNITED STATES 1125

(grants and contracts) directly to public and non- 1962, appealing to disease theory, the U.S. Su- profit agencies; the other was a formula-grant pro- preme Court struck down a California statute that gram, which allocated money to states based on a made drug addiction per se a crime. Medical treat- formula accounting for per capita income, popula- ment, not the ‘‘cruel and unusual punishment’’ of tion, and demonstrated need. incarceration, was the Court’s desideratum.In NIAAA aggressively sought state adoption of the 1963, the President’s Advisory Commission on model Uniform Alcoholism and Intoxication Treat- Narcotic Drug Abuse made substantially similar ment Act, first drafted in 1971 by the National recommendations. Conference of Commissioners on Uniform State It was the experimental success of METHADONE Laws. Section 1 of the Uniform Act, as it was MAINTENANCE that finally altered the discussion of known, stated that ‘‘intoxicated persons may not be opioid maintenance. Methadone, a synthesized subject to criminal prosecution because of their drug with opioid properties, was invented by Ger- consumption of alcoholic beverages but rather man pharmacologists during World War II and had should be afforded a continuum of treatment.’’ By been used at the U.S. PUBLIC HEALTH SERVICE 1980, thirty states had adopted some version of the HOSPITAL at Lexington to block addicts’ with- Uniform Act, thereby decriminalizing public drawal symptoms. In 1963 and 1964, with the drunkenness. support of the prestigious Rockefeller University, The thrust of federal and state grant making was medical researchers Vincent Dole and Marie to create an effective system of community-based Nyswander began to study its wider use in the alcoholism treatment services. This occurred in treatment of heroin addiction. Their research tandem with the deinstitutionalization process that proceeded despite opposition by the federal Bureau was rapidly depopulating state mental hospitals. of Narcotics, and was first published in 1965. The Although we customarily think of deinstitu- remarkable changes they observed in their patients tionalization as affecting only the mentally ill, in soon were replicated by other scholars. Methadone fact it had an important impact on alcoholics. In maintenance attracted considerable notoriety and 1960, a decade before deinstitutionalization began generated newenthusiasm for maintenance as a in earnest, thirty-six states had provisions specifi- strategy of treatment. cally for the involuntary hospitalization of ‘‘alco- Methadone maintenance did not become wide- holics,’’ ‘‘habitual drunkards,’’ and ‘‘inebriates.’’ spread overnight, however, and it has never been In addition, many states had voluntary-admission without controversy. The most fundamental criti- statutes. By the mid-70s, however, these laws were cism of maintenance has always been that it prehistory. Prepared or not, local communities had to sumes ‘‘incurability,’’ encourages users to continue provide. to rely on a narcotic medication, and thereby un- The alcoholism-treatment field was not static dermines abstinence-based approaches. During the during the 1980s. The federal ‘‘block grant sys- 1960s, and especially during the 1970s, when tem,’’ stringent drunk-driving laws, and the rise of methadone maintenance programs expanded dra- EMPLOYEE ASSISTANCE PROGRAMS (EAPs) and in- matically, this criticism came mainly from two surance coverage for treatment, all important de- sources: (1) abstinence-based programs run by re- velopments, will be discussed following a descrip- covering addicts more or less in the mutual-aid tion of the modern era of drug treatment. tradition and (2) minority poverty activists who sawin methadone a palliative strategy to treat what they sawas a symptom of economic deprivation DRUG TREATMENT without addressing its causes. Even by the late 1950s, the tough law, anti- Opposition from those working in the mutual- maintenance consensus of an earlier era of drug aid tradition came chiefly from veterans of control and treatment was breaking down. A joint THERAPEUTIC COMMUNITIES inspired by Synanon report of the American Bar Association and the (established in Southern California in 1958) and American Medical Association in 1958, finally pub- Daytop Village (opened in NewYork City in 1964). lished in 1961, cautiously favored outpatient treat- While most therapeutic communities sawaddiction ment and limited opioid maintenance as alterna- primarily as a result of characterological deficits tives to ‘‘threats of jail or prison sentences.’’ In and immaturity, some drewfinancial support from 1126 TREATMENT, HISTORY OF, IN THE UNITED STATES the Office of Economic Opportunity (OEO), the treatment capacity was also notable for its atten- short-lived, principal arm of the War on Poverty, tion to problems associated with a variety of drugs. and relied on an analysis of heroin addiction that It came at a time of sharp increase in marijuana use located its social sources in adaptations to poverty. among middle-class youth, an epidemic of amphet- This was an important theme of much scholarship amine use, growing experimentation with LSD, and on addiction during and after the late 1950s. In this media preoccupation with the counterculture, or analysis, still vital today, no form of treatment is the ‘‘youth revolt.’’ Thus, the political urge to pro- effective without job and community development vide treatment was fueled by two enduring con- to support aftercare and prevent relapse. Descend- cerns of Americans—unconventional and disor- ing from the mental hygiene tradition, this view derly behavior by young people and minority group provided a rationale for great skepticism about any members; and the connection between drug use narrowmedical approach that wasproclaimed as a and crime. Anything that might work was tried. ‘‘solution’’ rather than as a first step. There was The administration of President Richard M. (and remains) no inherent contradiction between Nixon took office in 1969 and made the connection maintenance and antipoverty strategies, and many between drugs and crime a priority, concentrating workers in antipoverty programs embraced metha- first on lawenforcement, federal legislation (the done as a viable and useful treatment. But many CONTROLLED SUBSTANCES ACT of 1970), and a re- did not, and the result was an uneasy pluralism in organization of federal enforcement agencies. In drug-treatment approaches. In 1966, when New 1970, while the administration was beginning to York City launched a major expansion of treatment consider the role of treatment in its overall strategy, for drug addiction, it chose to make drug-free ther- heroin use among service personnel in Vietnam apeutic communities the centerpieces of its effort. captured media attention. In response, on June 17, The middle to late 1960s were marked by a 1971, Nixon declared a War on Drugs and created, modest expansion of publicly supported programs by executive order, the SPECIAL ACTION OFFICE FOR for drug addiction, characterized by competition DRUG DBUSE PREVENTION (SAODAP) within the among a variety of distinct and sometimes incom- executive office of the president. He appointed as patible treatment philosophies: therapeutic com- director Dr. Jerome H. Jaffe, a psychiatrist and munities; methadone maintenance programs; com- pharmacologist from the University of Chicago and pulsory treatment with prolonged residential the director of the Illinois Drug Abuse Programs. components; twelve-step programs; overtly reli- SAODAP was the first in a two-decade series of gious programs; and a number of traditional men- differently named White House special offices con- tal-health approaches offering detoxification fol- cerned with the drug problem; Jaffe was the first in lowed by supportive psychotherapies. a series of so-called Drug Czars (though the title Despite the variety of approaches, accessibility might most appropriately fit Harry ANSLINGER, au- to voluntary treatment remained limited through- tocratic boss of the Bureau of Narcotics for over 30 out the 1960s. In 1968, NIMH undertook a survey years.) to identify every private or public program focused The creation of SAODAP marked the federal on the treatment of drug addiction in the United government’s first commitment to make treatment States; it located only 183. Most of these were in widely available. Indeed, SAODAP’s goal was to NewYork, California, Illinois, Massachusetts, Con- make treatment so available that addicts could not necticut, and NewJersey. Of these, 77 percent had say they committed crimes to get drugs because been open for less than 5 years. Only the federal they could not obtain treatment. Over the next hospitals at Lexington and Fort Worth had been in several years, a variety of community-based pro- operation for 20 years or more. grams were initiated and/or expanded. The major In addition to establishing the federal civil com- modalities were drug-free outpatient programs, mitment program, the Narcotic Addict Rehabilita- methadone maintenance, and therapeutic commu- tion Act of 1966 authorized NIMH to make grants nities. SAODAP deliberately deemphasized hospi- to establish community-based treatment programs. tal-based programs, allowing the civil commitment The first of these were awarded in 1968; they pro- program under NARA to wither away. Even so, the vided federal support for therapeutic communities need to expand treatment for the Veterans Admin- and methadone maintenance. This expansion of istration (VA) resulted in funding VA hospitals to TREATMENT, HISTORY OF, IN THE UNITED STATES 1127 use their beds for both detoxification and rehabili- expanded and improved treatment. One of Carter’s tation. SAODAP fully supported methadone main- close advisors, Dr. Peter Bourne, was a psychiatrist tenance, regarded as experimental by NIMH and who had established treatment programs in Geor- federal law-enforcement agencies, and became a gia and who had worked briefly in SAODAP during focal point of controversy as it presided over the the Nixon administration. Bourne enjoyed more dramatic growth of methadone programs begin- White House influence than any previous presiden- ning in the early 1970s. Treatment within the mili- tial advisor on drug issues. However, Bourne re- tary also was legitimized as an alternative to court signed in July 1978, and in the wake of his resigna- martial. tion, drug issues resumed their lowprofile. SAODAP was given a legislative basis in 1972. Resources for treatment from 1978 to 1980 were The same legislation, the Drug Office and Treat- stagnant despite an unprecedented inflation rate. ment Act, also created a formula grant program for Measured in 1976 dollars, the level of federal drug treatment comparable in intent to that for support for treatment was cut almost in half be- alcoholism treatment. The legislation required the tween 1976 and 1982. The Ford, Carter, and Rea- production of a written National Strategy, and au- gan administrations all presided over this decline. thorized establishment of the NATIONAL INSTITUTE At the same time, as the result of the impact of ON DRUG ABUSE (NIDA), analogous to NIAAA. Like inflation on the cost of state and local government, NIAAA, NIDA was lodged within NIMH. these jurisdictions also curtailed their support, thus During its first two years, SAODAP directed an aggravating the impact of federal reductions. unprecedented expansion of treatment. In early However, the Reagan administration was ideo- 1971 there were 36 federally funded treatment logically different from its predecessors—it was programs in the United States. By January 1972 characterized by considerable skepticism about there were 235, and by January 1973, almost 400. federal activism in general and about the efficacy of For a brief, 3-year period, the federal resources drug treatment in particular. Although it increased allocated to treatment, prevention, and research resources for lawenforcement and supply control exceeded those allocated to lawenforcement, actu- and introduced a stringent policy of ZERO TOLER- ally comprising two-thirds of the drug resources in ANCE that filled American prisons and newly popu- the 1973 federal budget. lar (though hardly innovative) therapeutic boot In 1973, Dr. Robert Dupont, also a psychiatrist, camps with drug offenders, the Reagan administra- succeeded Jaffe at SAODAP. Dupont had estab- tion downplayed treatment in favor of preven- lished and directed a treatment program in Wash- tion—especially First Lady Nancy Reagan’s ‘‘Just ington, D.C., and had extensive experience with Say No’’ campaign and the president’s public advo- methadone treatment. He extended the work of cacy of widespread drug testing of employees in SAODAP and then provided for continuity of policy industry and government. The 1980 reorganization when he became the first director of NIDA. of the federal block grant program that supported During the administration of President Gerald both alcohol and drug treatment combined these R. Ford (August 1974–January 1977), the sense of funds into an Alcohol, Drug Abuse and Mental urgency about drug problems declined. This was Health Services (ADMS) block grant and turned not due to indifference; it reflected a belief that the these funds over to the states. In the process, overall metaphor of war was not appropriate to a problem funding was reduced from 625 million to 428 mil- that might be controlled but was unlikely ever to be lion dollars and federal oversight was virtually eliminated. The recent lesson of Vietnam—that abandoned. After 1984, federal regulation required wars must be quickly won to be popular—was not that a certain percentage of these funds be spent on lost on Ford’s advisors. Thus, Ford did not appoint prevention rather than treatment. The Institute of a Drug Czar, leaving coordination of drug activities Medicine estimated that the proportion of the to a unit within the Office of Management and ADMS block funds available to support drug treat- Budget. There were no sharp changes in policy, but ment fell from 256 million dollars in 1980 to 93 the treatment budget was substantially reduced million dollars in 1986—and this estimate did not from the highwater mark of the Nixon era. account for inflation. The administration of President Jimmy Carter In spite of the Reagan administration’s lack of heightened the expectations of those interested in interest in drug treatment, congressional interest 1128 TREATMENT, HISTORY OF, IN THE UNITED STATES was rekindled. It was apparent by 1984 that HIV Beny J. Primm, a major figure in drug treatment, was being transmitted among drug injectors and by was recruited to organize OTI and to be its first drug injectors to others, especially their female director. OTI was given responsibility for oversight partners and their fetal young. Crack, an extremely of the block (formula) grant for drug and alcohol potent and inexpensive form of smokable cocaine, treatment and prevention and was given new au- was being aggressively marketed in areas of con- thority and budget resources to make grants for centrated poverty, although it took the deaths of treatment-demonstration projects. several prominent athletes, particularly Len Bias, a In 1992, Congress decided that the placement of first-round draft choice of the Boston Celtics, to OTI and OSAP within ADAMHA, which also pique concern with the growing use of cocaine. housed NIDA, NIAAA, and NIMH, was leading to Prodded by Congress, the second Reagan adminis- conflicts between the missions of research and those tration, in its closing years, did increase funding for of treatment and prevention. In still another reor- both research and treatment. However, according ganization, the three research institutes—NIDA, to the Institute of Medicine, these increases did not NIAAA, and NIMH—were transferred to the Na- compensate for the effects of previous budget cuts tional Institutes of Health (NIH), and the remain- and inflationary erosion. Adjusted for inflation, ing service functions were incorporated into a new public funding for drug treatment in 1989 (the last agency, the SUBSTANCE ABUSE AND MENTAL Reagan budget) was substantially below the level of HEALTH SERVICES ADMINISTRATION (SAMHSA). 1972 through 1974, the opening years of Nixon’s SAMHSA was composed of three centers: the Cen- War on Drugs. ter for Substance Abuse Prevention (CSAP), con- Even so, the Reagan administration retained its sisting primarily of the former OSAP; the Center emphasis on lawenforcement and prevention. To for Substance Abuse Treatment (CSAT), consisting better focus on prevention, in 1987 it created the primarily of the former OTI; and the Center for Office for Substance Abuse Prevention (OSAP), Mental Health Services (CMHS), consisting of the placing it within the Alcohol, Drug Abuse, and service-demonstration grant projects that were for- Mental Health Administration (ADAMHA). Most merly within NIMH. prevention activities carried out by the National Succeeding President Bush in 1992, President Institute on Drug Abuse (NIDA) were transferred to Bill Clinton appointed Dr. Lee Brown as his Drug OSAP, the first director of which was Dr. Elaine Czar. Brown, a criminologist by academic training, Johnson. had been a police chief in NewYork and Texas. In 1989, President George H. Bush reinvigo- Although there were some signs within the admin- rated the position of drug czar when he appointed istration that drug treatment was understood to be Dr. William Bennett, former secretary of education an important part of attacking persistent jobles- in the Reagan administration, to head his new sness and welfare dependency, the early Clinton White House drug policy office, the Office of Na- budgets made only slight shifts in resource alloca- tional Drug Control Policy (ONDCP). ONDCP was tion. Further, as Clinton’s health-care reform, wel- charged with coordinating demand-side (preven- fare reform, and crime and employment strategies tion and treatment) and supply-side (lawenforce- became hostage to management of the national ment) matters relating to drugs. There were in- budget deficit and partisan politics, no major initia- creases in resources for treatment—and even more tives specifically on drug treatment were intro- substantial increases in law-enforcement efforts. duced during the first two years he was in office. Although Bennett had recruited a noted drug-abuse Some provisions for more treatment within the scholar, Dr. Herbert Kleber, as his deputy for de- criminal-justice system were part of the original mand-side activity, the ONDCP chief and his staff crime bill. As a result of the recession of the early remained skeptical about the value of treatment, 1990s, and faced with the necessity of accommo- continuing the decade-long policy of emphasizing dating in their jails and prisons huge numbers of prevention and lawenforcement. drug offenders incarcerated on mandatory sen- Later in 1989, much of the authority and fund- tences, states and counties also failed to restore the ing for drug treatment was transferred from NIDA support an earlier era provided for treatment. In to another newagency created withinADAMHA, some cases, they retrenched considerably. In 1996, the Office for Treatment Improvement (OTI). Dr. Brown was succeeded as Drug Czar by General TREATMENT, HISTORY OF, IN THE UNITED STATES 1129

Barry McCaffrey. Although McCaffrey signaled an creasingly under pressure to find sources of funds early intent to shift federal resources toward the other than public grants and contracts and pay- treatment of America’s ‘‘three million hard-core ments from medical programs for the indigent users’’ (as he put it during his confirmation hear- (such as Medicaid). Sliding fee scales became more ing), his performance in office took quite a different commonly used, and in some places scarce public turn. By 1998, it was clear that McCaffrey’s princi- treatment slots were absorbed by fee-paying drink- pal concern was interdiction, especially in Mexico, ing drivers mandated to treatment by stricter pen- and his budgets reflected this continuing emphasis. alties for drunk driving and more systematic en- Although the 1999 federal drug budget included a forcement of such laws. $143 million increase in the federal block grant for The growth of the private sector was spurred as drug treatment, two-thirds of the funds remained well by EMPLOYEE ASSISTANCE PROGRAMS (EAPs), committed to supply reduction. efforts to intervene in alcohol and/or drug problems at places of employment. This strategy goes A TWO-TIERED SYSTEM back at least to the Washingtonian movement, but formal EAPs date from the 1940s. Their ranks Beginning in the 1970s and promoted by swelled during the 1970s and 80s. Generally, EAPs NIAAA, NIDA, and a fewinsurance industry lead- referred people with more serious alcohol and drug ers like The Travelers, health insurance policies be- problems to formal—usually private—treatment gan to provide coverage for the treatment of alcohol programs, which were paid primarily by fees de- and drug dependence. Sometimes this was the re- rived from third-party payers, such as insurance sult of labor negotiations; sometimes it was the companies, who in turn derived their funds from result of state insurance commission mandates for policies paid for or subsidized by employers. The its inclusion. In response to the availability of sup- sharply rising cost to employers of providing alco- port, private hospitals (both nonprofit and for- hol and drug treatment was a major factor in the profit) expanded their treatment capacities dra- rise of managed care, which was aimed initially at matically. There had been no such growth in the controlling the cost of mental health and alcohol private-treatment sector since the boom of the ine- and drug treatment. The major mechanism by briate asylum era. which the managed-care industry addressed the Commonly, treatment programs within the pri- cost of treatment was to challenge the practice of vate sector were based on the Minnesota model, using several weeks of inpatient care as the initial emphasizing twelve step principles and employing phase of treatment for alcohol and drug depen- recovering people. Such programs typically con- dence. In practice, treatment providers were told sisted of a brief period of inpatient detoxification that inpatient treatment beyond a fewdays could followed by several weeks of inpatient rehabilita- not be justified and would not be paid for under the tion. Twenty-eight days was such a common dura- insurance policy. tion of inpatient care that the programs often were The success of managed care in reducing costs referred to as 28-day programs. The posthospital by constraining the use of inpatient treatment re- phase of treatment usually consisted of participa- sulted in a dramatic growth of managed-care orga- tion in AA, Narcotics Anonymous, or Cocaine nizations and an equally significant contraction Anonymous. and restructuring of the private alcohol and drug Such programs—often called chemical-depen- treatment system. By the early 1990s, a number of dency programs because they admitted people with states had obtained federal permission to use man- drug and alcohol problems—catered almost exclu- aged-care approaches to contain the costs of treat- sively to those with health insurance. (In many ment for individuals covered by federal programs instances, they represented important profit centers like Medicaid. The future of funding for treatment, for medical institutions needing to subsidize finan- the various public grant and contract programs cial losses from other services, like emergency notwithstanding, is inseparable from the broader rooms.) Those without insurance either had no ac- national debate on the financing of health care. cess to treatment or made use of the network of In 1990, the Institute of Medicine described U.S. publicly supported programs—a network that be- treatment arrangements as a two-tiered system, came increasingly thin during the 1980s and in- comprised of public and private sectors, in which 1130 TREATMENT IN THE FEDERAL PRISON SYSTEM

the private sector served 40 percent of the patients Health Care Services, Institute of Medicine. Washing- but garnered 60 percent of total treatment expendi- ton, DC: National Academy Press. tures. Although the ratio of patients to revenues COURTWRIGHT, D. T. (1982). Dark paradise: Opiate ad- cannot be known for earlier eras, this two-tiered diction in America before 1940. Cambridge: Harvard structure is a creature of the nineteenth century, University Press. when treatment was established both as a public COURTWRIGHT, D., JOSEPH, H., & DES JARLAIS, C. (1989). good and a commodity. Barring some revolution in Addicts who survived: An oral history of narcotic use the organization of U.S. health care, this is unlikely in America, 1923–1965. Knoxville: University of to change soon. What remains to be seen is what the Tennessee Press. balance of public and private treatment will be, GERSTEIN, D. R., & HARWOOD,H.J.(EDS.). (1990). what innovations or reinventions will be born of Treating drug problems. Committee for the Substance financial necessity, or as the result of homeless ad- Abuse Coverage Study, Division of Health Care Ser- dicts and a groaning correctional system. History vices, Institute of Medicine. Washington, DC: Na- allows us to predict the likely questions, but it is not tional Academy Press. a very reliable guide to specific answers. INSTITUTE OF MEDICINE. (1990). Broadening the base of treatment for alcohol problems. Report of a Study by (SEE ALSO: Disease Concept of Alcoholism and a Committee of the Institute of Medicine, Division of Drug Abuse; Temperance Movement; Treatment Mental Health and Behavioral Medicine. Washington, Types; U.S. Government: Drug Policy Offices in the DC: National Academy Press. Executive Office of the President; U.S. Government: JAFFE, J. H. (1979). The swinging pendulum: The treat- The Organization of U.S. Drug Policy) ment of drug users in America. In R. I. Dupont, A. Goldstein, & J. O’Donnell (Eds.), Handbook of drug abuse. Washington, DC: U.S. Government Printing BIBLIOGRAPHY Office. BAUMOHL, J. (1993). Inebriate institutions in North MUSTO, D. F. (1999). The American disease: Origins of America, 1840–1920. In C. Warsh (Ed.), Drink in narcotic control. NewYork: Oxford University Press. Canada: Historical essays. Montreal: McGill-Queens RUBINGTON, E. (1991). The chronic drunkenness of- University Press. fender: Before and after decriminalization. In D. J. BAUMOHL, J. (1986). On asylums, homes, and moral Pittman & H. R. White (Eds.), Society, culture, and treatment: The case of the San Francisco Home for drinking patterns reexamined. NewBrunswick,NJ: the Care of the Inebriate, 1859–1870. Contemporary Rutgers Center for Alcohol Studies. Drug Problems, 13, 395–445. TICE, P. (1992). Altered states: Alcohol and other drugs BAUMOHL, J., & ROOM, R. (1987). Inebriety, doctors, and in America. Rochester, NY: The Strong Museum. the state: Alcohol treatment institutions before 1940. WHITE, W. L. (1998). Slaying the dragon: The History of In M. Galanter (Ed.), Recent developments in alcohol- addiction treatment and recovery in America. Bloom- ism, vol. 5. NewYork: Plenum. ington, IL: Chestnut Health Systems/Lighthouse In- stitute. BAUMOHL, J., & TRACY, S. (1994). Building systems to manage inebriates: The divergent paths of California JIM BAUMOHL and Massachusetts, 1891–1920. Contemporary Drug JEROME H. JAFFE Problems, 21, 557-597. BESTEMAN, K. J. (1991). Federal leadership in building the national drug treatment system. In D. R. Gerstein TREATMENT IN THE FEDERAL & H. J. Harwood (Eds.), Treating drug problems, vol. PRISON SYSTEM The federal prison system 2. Committee for the Substance Abuse Coverage of the United States has made repeated efforts to Study, Division of Health Care Services, Institute of treat drug-abusing prisoners. The issue was first Medicine. Washington, DC: National Academy Press. raised in 1928 by the chairman of the Judiciary COURTWRIGHT, D. T. (1991). A century of American nar- Committee of the U.S. House of Representatives. cotic policy. In D. R. Gerstein & H. J. Harwood He reported that the three then-existing federal (Eds.), Treating drug problems, vol. 2. Committee for penitentiaries—Atlanta, Leavenworth, and McNeil the Substance Abuse Coverage Study, Division of Island— held 7,598 prisoners, 1,559 of whom were TREATMENT IN THE FEDERAL PRISON SYSTEM 1131

‘‘drug addicts.’’ To deal with these prisoners he tion of national drug-abuse coordinator was cre- called for a ‘‘broad and constructive program in ated to oversee drug-abuse treatment efforts combatting the drug evil,’’ and he recommended throughout the federal prison system. the establishment of special federal ‘‘narcotics At the end of 1990, the BOP held some 59,000 farms’’ for the ‘‘individualized treatment’’ of drug- prisoners. About 54 percent of federal prisoners abusing prisoners. He hoped that there would be- were serving sentences for drug-related crimes. At come institutions that ‘‘will reduce and also prevent the time of their admission, 47 percent of federal crime . . . and greatly alleviate the suffering of prisoners were classified as having moderate to se- those who have become addicted.’’ rious drug-abuse problems. Under the BOP’s clas- In 1930, the U.S. Bureau of Prisons (BOP) was sification scheme, a moderate problem designation established to handle the burgeoning population of indicates that the inmate’s use of drugs or alcohol federal prisoners, caused mainly by the enforce- had negatively affected at least one ‘‘major life ment of PROHIBITION. The BOP’s first directorate area’’—school, health, family, financial, or legal was eager to launch special programs for drug- status—in the two-year period prior to arrest. abusing prisoners, but many in Congress and else- In 1991, the BOP’s drug-education program was where believed that prisons should have little or no required for all inmates with any history of drug direct role in treating drug-abusing offenders. A abuse or drug-related crime. By the end of 1992, an compromise was struck. The U.S. Public Health estimated 12,000 to 15,000 federal inmates com- Service (USPHS) was authorized to establish and pleted drug-education programs. Counseling ser- administer two hospitals that would offer state-of- vices—ALCOHOLICS ANONYMOUS (AA), NARCOTICS the-art drug-abuse treatment, and the BOP was ANONYMOUS (NA), group therapy, stress manage- permitted to freely assign addict prisoners to the ment, prerelease planning—were available on an facilities. The first USPHS HOSPITAL opened in ongoing basis at most federal prisons, and the BOP 1935 at Lexington, Kentucky; the second was planned to make them available to inmate volun- opened in 1938 at Fort Worth, Texas. teers at all institutions at any time during their incarceration. REHABILITATION EFFORTS Transitional drug-abuse treatment services were being developed throughout the BOP. The adminis- In the 1960s, a broad consensus emerged that tration of these services were divided into two six- prisons should do whatever possible to rehabilitate month components, each of which included indi- drug-abusing inmates. In 1966, Congress passed vidual and family counseling, assistance in identi- the NARCOTIC ADDICT REHABILITATION ACT fying and obtaining employment, and random (NARA), which, among other initiatives, ordered urine testing. The first component was provided in in-prison and aftercare treatment for narcotic ad- the BOP’s community corrections centers; the sec- dicts who had been convicted of violating federal ond component was provided as post-release after- laws. Between 1968 and 1970, the BOP established care, in conjunction with the Probation Division of NARA-mandated drug-treatment units within five the Administrative Office of the U.S. Courts. of its prisons. In the 1970s, the BOP assumed direct To assess the effectiveness of its current multidi- control over both USPHS hospitals and began to mensional drug-abuse treatment efforts, the BOP develop an extensive network of programs for the has begun a major evaluation of these programs treatment of drug-abusing prisoners throughout that will analyze data on both in-prison adjustment the system. In 1979, the BOP required the develop- and postrelease behavior for up to five years after ment of NARA-standard drug-treatment programs release. in all its prisons, publishing it Drug Abuse Incare Manual. In 1985, the BOP established a task force (SEE ALSO: Coerced Treatment for Substance Of- to evaluate the state of drug-abuse treatment pro- fenders; Prisons and Jails, Drug Treatment in) grams within federal prisons. The review found that administrative problems had hampered the BIBLIOGRAPHY BOP’s drug-treatment efforts. In response, in 1986, the position of chemical-abuse coordinator was es- DIIULIO, J. J., JR. (1992). Barbed-wire bueaucracy: tablished within each prison, and in 1988, the posi- Leadership, administration, and culture in the Fed- 1132 TREATMENT OUTCOME PROSPECTIVE STUDY (TOPS)

eral Bureau of Prisons. NewYork: Oxford University admitted in 1979; follow-ups 90 days and 1 year Press. after treatment of 2,300 clients who entered treat- KEVE, P. W. (1990). Prisons and the American con- ment in 1980; and follow-ups 3 to 5 years after science: A history of U.S. federal corrections. Carbon- treatment of 1,000 clients who entered programs in dale, IL: Southern Illinois University Press. 1981. Professional field interviewers hired, trained, U.S. DEPARTMENT OF JUSTICE,FEDERAL BUREAU OF PRIS- and supervised by RTI field staff were able to locate ONS. (1991). State of the bureau 1990: Effectively and interviewbetween70 and 80 percent of the managing crowded institutions. Washington, DC: Au- clients selected for these interviews. thor. TOPS has resulted in a substantial body of im- U.S. DEPARTMENT OF JUSTICE,FEDERAL BUREAU OF PRIS- portant knowledge about drug-abuse treatment ONS,OFFICE OF RESEARCH AND DEVELOPMENT. (1990). and treatment effectiveness. The client populations Proposal for the evaluation of the Federal Bureau of of outpatient METHADONE PROGRAMS, long-term Prisons drug abuse treatment programs. Washington, residential programs, and outpatient drug-free DC: Author. programs who participated in TOPS differed on WALLACE, S., ET AL. (1991). Drug treatment. Federal many sociodemographic and background charac- Prisons Journal, 2 (3), 32–40. teristics. The residential clients were significantly JOHN J. DIIULIO,JR. more likely to report multiple use of drugs, more drug-related problems, suicidal thoughts and attempts, heavy drinking, predatory crimes, and less TREATMENT OUTCOME PROSPEC- full-time employment compared to the methadone TIVE STUDY (TOPS) This is a prospective clients. Outpatient drug-free clients were more clinical, epidemiological study of clients who en- likely than methadone clients to report drug-re- tered drug-abuse treatment programs from 1979 to lated problems, suicidal thoughts or attempts, 1981. During the course of TOPS, 11,182 clients predatory crimes, and heavy drinking, but they were interviewed at admission to drug-abuse treat- were less likely than residential clients to use multi- ment by program researchers hired to work in as- ple drugs. These results demonstrated that each signed clinics and professionally trained and super- type of program served very different, important vised by Research Triangle Institute (RTI) field segments of the drug-abusing population. The high staff. The interviews at admission covered demo- rates of self-referrals to methadone (48%) and graphics, history of drug use, treatment, arrest and criminal-justice referrals to residential and outpa- employment behavior in the year prior to treat- tient drug-free treatment (31%) suggest differ- ment, and status upon admission to treatment. The ences in clients’ motivations for seeking treatment study was sponsored by the NATIONAL INSTITUTE and, consequently, differences in retention, services ON DRUG ABUSE (NIDA) and by the RTI. The study received, and outcomes. population included 4,184 clients from 12 outpa- The drug-abuse patterns reveal the differential tient methadone programs, 2,891 clients from 14 concentration of types of drug abusers across the residential programs, and 2,914 clients from 11 major categories. Clients on methadone were pri- outpatient drug-free programs in 10 cities. Inter- marily (52%) traditional heroin users who used views with questions on behavior, services received, only cocaine, marijuana, and alcohol, in addition and satisfaction were collected by the program re- to heroin. One in five of these clients, however, searchers every three months while clients re- used heroin and other narcotics, as well as a vari- mained in treatment. The self-report data were ety of non-narcotic drugs. The remaining quarter supplemented with data abstracted from the clini- of clients on methadone were classified as former cal and medical records of all clients selected for the daily users who had histories of regular use but did follow-up, and questionnaires describing the treat- not use heroin on a weekly or daily basis in the ment philosophy, structure, practice, and process year before treatment. Residential clients had di- were completed by counselors and program verse patterns of use, and the majority of outpa- directors. tient drug-free clients were users of alcohol and The follow-up data included interviews 1 and 2 marijuana (36%) or single non-narcotics users years after treatment with 1,130 clients who were (22%). TREATMENT OUTCOME PROSPECTIVE STUDY (TOPS) 1133

Symptoms of depression are very commonly re- abuse rather than addressing the client’s multiple ported by clients entering drug-abuse treatment drug use, drug-related problems, and social and programs. Overall, about 60 percent of TOPS cli- economic functioning. Low-dose methadone (69% ents reported at least one of three symptoms of of the clients admitted were initially treated with depression at intake: nearly 75 percent of the less than 30 mg of oral methadone daily) was the women under 21 years of age reported one or more most common pattern of methadone treatment in symptoms of depression. Other results suggest that the programs participating in TOPS. the duration of regular drug use and the number of In TOPS, multiple measures of treatment out- prior treatment episodes are important indicators of the effectiveness of any single treatment episode; come were necessary to describe changes in the clients with lengthy drug-abuse or drug-treatment client’s ability to function in society after treat- histories have poorer prognoses. ment. In general, clients who remained in treat- Clients who have come into treatment by way of ment at least three months had more positive post- the criminal justice system do as well or better than treatment outcomes, but the major changes in be- other clients in drug-abuse treatment. Formal or havior were seen only in those who remained in informal mechanisms of the criminal justice system treatment for more than twelve months. Analyses appear to refer individuals who had not previously of the TOPS data showthat the post-treatment been treated and many who were not yet heavily rate of daily heroin, cocaine, and psychotherapeu- involved in drug use. Involvement with the criminal tic-agent use among clients who spent at least justice system also helps retain clients in treatment three months in treatment was half that of the up to an estimated six to seven additional weeks. pretreatment rate. The post-treatment rates of Drug abuse treatment programs vary in the nature weekly or more frequent use for clients who stayed and intensity of the treatment services provided, in treatment at least three months were 10 to 15 the types of therapists and therapies provided, the average length of stay, and the inclusion or exclu- percent lower than the rates for shorter-term cli- sion of aftercare. ents. The results showed that time spent in treat- The study of the treatment process in TOPS pro- ment was among the most important predictors of grams focused on many important aspects of the most treatment outcomes. Stays of one year or structure, nature, duration, and intensity of drug- more in residential or methadone treatment, or abuse treatment. Descriptions of aspects of the continuing maintenance with methadone, pro- treatment process were developed from clients’ duced significant decreases in the odds of a client self-reports of needs for treatment services, services using heroin in the follow-up period. Clients in received, and satisfaction, combined with abstrac- TOPS also reported a substantial decrease in de- tions of clinical and medical records and descrip- pression symptoms during the years after tions of programs by counselors and directors. The treatment. outpatient methadone and outpatient drug-free Analyses of the effects of treatment on behavior treatment programs had budgets per slot of ap- have focused on reductions in predatory crime and proximately 2,000 dollars per year. Therapeutic communities had an average expenditure of 6,135 the costs associated with crime. The assessment of dollars per bed. the benefit/cost ratio indicates that substantial ben- The number of available services (medical, psy- efits are obtained in reductions of crime-related chological, family, legal, educational, vocational, costs regardless of the measures used within the and financial services) varied during the years year after treatment. Reducing transmission of the 1979 to 1981. Fewer services appeared to be avail- AIDS virus would increase the benefit portion of able in the later years of the study. The proportion benefit/cost ratio even more. of clients in residential treatment programs who received family, educational, and vocational ser- (SEE ALSO: Drug Abuse Treatment Outcome Study; vices decreased noticeably during the three-year Treatment Alternatives to Street Crime; Treatment period. During this same period, the clients’ demands for services increased. Programs in TOPS Types) appeared to focus on the client’s primary drug of ROBERT HUBBARD 1134 TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE

TREATMENT PROGRAMS, CENTERS, progress in meeting these expectations is moni- AND ORGANIZATIONS: AN HISTORICAL tored. Treatment at Hazelden is integrated with the PERSPECTIVE The development of treatment principles of ALCOHOLICS ANONYMOUS. programs for the age-old problem of drug and alcohol abuse has been a fairly recent phenomenon. SYNANON Most formal treatment programs were founded in the latter half of the twentieth century; the mid- Founded in 1958 by Charles E. Dederich, 1960s were a period of significant focus on U.S. Synanon pioneered a breakthrough approach to the social programs. Growing out of President Lyndon treatment of drug dependence. Using some of the B. Johnson’s Great-Society strategy was a new way approaches he had personally experienced in of viewing the community’s capacity to take owner- ALCOHOLICS ANONYMOUS, a mixture of self-reliance ship of its social problems, develop collaborative and Buddhist philosophies, and his own bombastic strategies, and heal its own wounds. Toward that interpersonal style, Dederich shaped a self-help or- end, a newlexicon emerged— community-based, ganization that grewfrom a small storefront in storefront, and streetworker—to identify but a few Santa Monica, California, to over 2,000 members terms. The programs that evolved from this move- in multiple residential settings across the United ment employ a variety of treatment philosophies; States by the early 1970s. The organization some treatment centers target a specific gender, amassed considerable wealth, and as it became ethnic, or age group. This article presents an over- more self-sufficient, Synanon members began to viewof some significant drug and alcohol abuse consider their process a religion. By the mid-1970s, treatment programs, centers, and organizations. the organization was engaging in controlling and even violent practices against its members, including forced vasectomies and abortions. The whole HAZELDEN FOUNDATION system also began to have increasingly violent in- Hazelden (PO Box 11, CO3, Center City, MN teractions with outsiders—including intimidation 55012-0011; 800-257-7810) was established in and actual physical assaults. The organization, so 1949; it was one of the pioneering programs that lauded in the press during its early years, became developed the approach to treatment that is now an object of national criticism. Then Dederich re- widely known as the MINNESOTA MODEL. Today, versed his earlier position of shunning chemicals the private, nonprofit Hazelden Foundation oper- and began to drink. In 1978, he was indicted for ates residential rehabilitation programs (main conspiracy to commit murder, and the court headquarters in Center City, Minnesota, with addi- instructed him to vacate leadership. A small cadre tional facilities in Illinois, Minnesota, NewYork, of members still venerated him until his death in and Florida) providing Minnesota Model treatment 1997. Synanon ceased its drug-treatment pro- for thousands of adult alcoholic, drug-dependent grams in the 1980s and is no longer involved in any men and women each year. Hazelden offers accred- human-service business. ited distance learning programs for addiction stud- Controversies aside, the methodologies devel- ies, and in 2000, granted its first master of arts oped and refined by Synanon became the precursor degrees in Addiction Counseling. for the drug-free THERAPEUTIC COMMUNITY ap- Residential treatment consists of an open-ended proach. This strategy has proven significantly ef- stay lasting an average of twenty-eight days. Pri- fective for both ADOLESCENTS and adults, regard- mary rehabilitation is done by a staff of trained less of the types of drug they use. counselors who are also working their own pro- The salient ingredients pioneered at Synanon re- grams of recovery. During the first week of primary main fundamentally intact in drug-free therapeutic rehabilitation, the staff concentrates on problem communities in the United States and elsewhere. identification, guided by assessments of psycholog- These fundamental ingredients fall into four major ical, spiritual, health, social activities, and chemi- categories: (1) behavior management and behavior cal-use profiles. After the client’s problem is identi- shaping, (2) emotional and psychological life, fied, an individual treatment plan is formulated (3) ethical and intellectual development, and both for and with the client. Goals, objectives, and (4) work and vocational life. Within each of these methods are identified in the treatment plan and categories, elaborate sets of techniques use deliber- TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE 1135 ate but artful dissonance and confrontation as In successive years, additional facilities were major tools for changing behavior. opened in Massachusetts and Connecticut. A facility for ADOLESCENTS in Middletown, Rhode Island, DAYTOP VILLAGE (ALSO DAYTOP began operating in 1970. While relatively short FOR A DRUG FREE WORLD) lived, it laid the groundwork for those modified therapeutic communities Marathon currently oper- Daytop Village, Inc. (54 West 40th Street, New ates throughout NewEngland. In February 1971, York, NY 10018; 212-354-6000), which began in Marathon acquired a historically significant prop- 1964, had its roots in a research project conducted erty in Dublin, NewHampshire, the Dublin Inn. In by Alex Bassin and Joseph Shelly of the Probation the 1990s, this facility became the center for three Department of the Second Judicial District of the distinct Marathon programs: the original New Supreme Court of New York. They were awarded a Hampshire adult therapeutic community, the grant from the National Institute of Mental Health Lodge at Dublin, a facility for male adolescents, to initiate a newapproach for treating drug-ad- and the Alcohol Crisis Intervention Unit, a small dicted convicted felons. This newapproach would social-setting detoxification facility. In 1999, Mar- offer an alternative to incarceration, in the form of athon became an affiliate of Phoenix House. a residential treatment center modeled roughly after Synanon. The founders of Daytop Village in- PHOENIX HOUSE cluded Dr. Daniel Casriel, David Deitch, a former Founded in 1967, Phoenix House (164 W. 74th Synanon director, and Monsignor William B. Street, NewYork, NY 10023; 212-595-5810) was O’Brien, a Roman Catholic priest. a second-generation THERAPEUTIC COMMUNITY Daytop’s primary effort was long-term residen- (TC) program that developed from the treatment tial treatment, but by the mid-1970s, day-care approach originated at SYNANON. Phoenix House models had been implemented, as well as discrete provides drug-free residential and outpatient treat- adult and adolescent programs. During the mid- ment for adults and adolescents, plus intervention 1980s, Daytop expanded its program to include and prevention services. Phoenix House operates working adults—both after work and during spe- programs in correctional facilities and homeless cial employer-contracted daytime hours. In the late shelters. It is one of the largest nongovernmental, 1980s Daytop instituted special programs for preg- nonprofit drug-abuse service agencies and has a nant women. 1-800-COCAINE substance-abuse information The basic assumption underlying the Daytop and referral service. treatment system is that drug dependence is a mix of educational, biomedical, emotional, spiritual, HAIGHT-ASHBURY FREE CLINIC and psychosocial factors—and the treatment environment must attend to all of these. This philoso- The Haight-Ashbury Free Clinic (558 Clayton phy serves as the basis for many successful treat- Street, San Francisco, CA 94117; 415-487-5632) ment programs. was founded in June 1967 by David E. Smith, M.D., with the help of other physicians from the MARATHON HOUSE University of California Medical School at San Francisco and community volunteers to provide In 1966, streetworkers for Progress for Provi- medical services for the waves of young people, dence (Rhode Island) began to acknowledge a known as hippies, who came to San Francisco dur- growing community presence of HEROIN, heroin ing the ‘‘Summer of Love.’’ These young people dealers, and addicts. Representatives from this or- often lived in crowded, unhygienic conditions and ganization pursued training with Daytop Village, were vulnerable to respiratory, skin, and sexually seeking technical assistance to establish a Provi- transmitted diseases. The Free Clinic offered an dence-based initiative. Marathon House, the first alternative to an established medical care system NewEngland-based T HERAPEUTIC COMMUNITY, that members of the Counterculture sawas difficult was established in Coventry, Rhode Island, in Octo- to access, dehumanizing, unresponsive, and often ber 1967. judgmental about their nontraditional lives. The 1136 TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE clinic’s philosophy included beliefs that health care is a right, not a privilege, and that it should be free and nonjudgmental. The free clinic became a source of innovative drug-abuse treatment, where many health professionals received their early field training, and treatment approaches were developed for the DETOXIFICATION of OPIOID,SEDATIVE-HYPNOTIC, stimulant, and PSYCHOACTIVE drug abusers. To- day, Haight-Ashbury Free Clinics, Inc., provides a full spectrum of community medical services to an ethnically mixed population of the working poor, the unemployed, and the HOMELESS.

GATEWAY FOUNDATION In 1968, Gateway Houses Foundation was incorporated as a not-for-profit corporation and became the first THERAPEUTIC COMMUNITY in Illinois. Modeled on DAYTOP VILLAGE, it was established as a residential setting in which former drug addicts could help other drug abusers find a way to live drug-free, useful lives in the community. The early years of treatment experience demonstrated that not all of those entering Gateway needed long-term residential treatment. Programs were devised or modified to fit the specific needs of the individuals served. The agency adopted the Volunteer medics sort through medicine name Gateway Foundation in 1983 to better sym- donations to the Haight Ashbury Free Clinic, a bolize the services offered. To extended care (resi- clinic specializing in the treatment of young drug dential, long-term treatment), Gateway added out- users. San Francisco, July 1967. ( Ted patient (both intensive and basic), detoxification, Streshinsky/CORBIS) and short-term treatment, as well as community- based EDUCATION and PREVENTION PROGRAMS. Oxford House in Silver Spring, Maryland. The The therapeutic community remains the core of stimulus for this first house was a decision by the Gateway’s programs. Participation in TWELVE- state of Maryland to save money by closing a pub- STEP support groups are the client’s mainstay dur- licly-supported halfway house. The men living in it ing and after treatment. Gateway Foundation’s decided to rent and operate the facility themselves. successful treatment center within the Correctional Operated democratically, residents of the house de- Center of Cook County (the largest U.S. county termined howmuch each wouldhave to pay to jail) resulted in treatment programs for inmates in cover expenses, developed a manual of operations, other Illinois and Texas correctional programs. and agreed to evict anyone who returned to sub- Treatment for all Gateway clients includes work stance use. When the first Oxford House found and social-skills development, continuing educa- itself with a surplus of funds, the residents decided tion, and employment counseling. to use the money to rent another house and expand the concept. Each subsequent house followed suit. There are nowseparate houses for men and OXFORD HOUSE women. In 2000, there were approximately 350 The autonomous halfway-house movement of houses in North America. the 1990s, Oxford House, Inc., owes its momentum While not affiliated in any way with AA or to J. Paul Molloy, who in 1975 established the first NARCOTICS ANONYMOUS (NA), the principles of TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE 1137 these groups are integral to the operation of each in San Francisco, CA. It consists of residential facil- Oxford House. Individuals can remain in residence ities for adults and adolescents, a day treatment as long as needed to become stably sober. The aver- program, outpatient services, and a nonpublic age length of stay is thirteen months. school and training institute. Walden House is a Although a recovery house can be self-run and highly structured program designed to treat the be- self-supported without being an Oxford House, if it havioral, emotional, and family issues of substance wishes to affiliate, it must file an application for a abusers. charter with Oxford House, Inc. (9314 Colesville The heart of the Walden House TC is a long- Road, Silver Spring, Maryland 20907). Oxford term residential treatment program, consisting of a House, Inc., a nonprofit corporation, does not own series of phases from orientation to aftercare. property, but helps groups wanting to start a new Within the TC, all the household tasks, groups, and house. seminars promote responsibility and emotional growth. The activities are part of an integrated SECOND GENESIS, INC. array of therapeutic experiences, in which residents Second Genesis, Inc. (7910 Woodmont Avenue, continuously see themselves in a context of mutual Suite 500, Bethesda, MD 20814; 301-656-1545), is support. The philosophy of Walden House empha- a long-term, residential and outpatient rehabilita- sizes self-help and peer support. tion program for adults and teenagers with sub- Founded in 1969 by Walter Littrell as a re- stance abuse problems. Founded in Virginia in sponse to the drug epidemic of the 1960s, Walden 1969, under the direction of Dr. Sidney Shankman, House has grown into one of the largest substance- Second Genesis is a nonprofit organization operat- abuse programs in California. The program pio- ing residential THERAPEUTIC COMMUNITIES and out- neered the use of alternative treatments with sub- patient services that serve Maryland, Virginia, and stance abusers, for example, herbs, diet, and physi- Washington, DC. Second Genesis admits adults, cal exercise. Walden House has designed many women and their young children, and teenagers. special programs to treat particular populations, The Second Genesis residential program has including clients with AIDS, homeless people, mi- been described as a school that educates people norities, pregnant women, mothers, and clients re- who have never learned how to feel worthy without ferred from the criminal-justice system as an alter- hurting themselves and others. Through highly native to incarceration. structured treatment, Second Genesis combines the basic values of love, honesty, and responsibility OPERATION PAR with work, education, and intense group pressure to help correct the problems that prevent people Operation PAR, Inc. (Parental Awareness & Re- from living by these values. Discovering self-responsibility) was founded in 1970 by Florida State spect in a family-like setting, residents are taught Attorney James T. Russell, former Pinellas County to replace behavioral deficits and substance abuse Sheriff Don Genung, County Commissioner Charles with positive alternatives. The Mellwood House fa- Rainey, and Shirley Coletti, a concerned parent. In cility in Upper Marlboro, MD, provides residential the years since its founding, PAR has developed one treatment for women and their young children, of- of the largest nonprofit systems of substance-abuse fering children’s services, vocational counseling, EDUCATION,PREVENTION,TREATMENT, and RE- parenting classes, and anger management work- SEARCH in the United States. At present, PAR oper- shops. In 1998, Second Genesis opened adult and ates more than twenty-five substance-abuse pro- adolescent outpatient programs, providing group grams in nineteen locations in Florida. Operation and individual therapy, educational services, and PAR’s THERAPEUTIC COMMUNITY (TC) has been in DWI/DUI counseling. continuous operation since 1974. The program targets individuals who are severely dysfunctional and WALDEN HOUSE who exhibit antisocial behaviors as a result of sub- Walden House (520 Townsend St., San Fran- stance abuse. The facility is an important alterna- cisco, CA 94103; 415-554-1100) is a comprehen- tive to incarceration for criminal courts throughout sive THERAPEUTIC COMMUNITY (TC), which began central Florida. Approximately 70 percent of clients 1138 TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE have histories of significant involvement with the and Alcohol Abuse. Abraxas’s founder, Arlene Lis- criminal-justice system. sner, had been the deputy clinical director for the Overall services provided by PAR TC include State of Illinois drug-abuse treatment system. individual and group counseling, counseling There were two mandates to the RFP: (1) that a groups for special populations, AA and NA support drug-treatment program be devised to directly groups, on-site educational services, vocational serve the juvenile and adult justice system, and training and a job placement program, work expe- (2) that the program would utilize a then-aban- rience, recreational therapy, and parenting therapy doned U.S. forest-service camp, Camp Blue Jay, and classes. In April 1990, services were expanded within the Allegheny National Forest. The original to include residential living, called PAR Village, for proposal stressed the development of a comprehen- the children of maternal substance abusers. sive program incorporating intensive treatment, education, and, of particular importance, a con- PROJECT RETURN FOUNDATION, INC. tinuum of care to assist residents to reenter through regional reentry facilities. After an initial attempt Project Return Foundation, Inc. (10 Astor Place, to use only a behavioral approach, a THERAPEUTIC 7th Floor, NewYork, NY 10003; 212-979-8800), COMMUNITY (TC) model was implemented. a nonprofit, nonsectarian, multipurpose human- By 1988, all Abraxas facilities had focused their services agency, operates several NewYork City target populations solely on adolescents and had residential drug-free (RDF) THERAPEUTIC-COMMU- become gender specific. For example, Abraxas V in NITY (TC) programs. The agency was founded in Pittsburgh was developed as an all-female residen- 1970 as a self-help and community center for substance abusers by two recovering addicts, Carlos tial facility. In 1990, an intensive project known as Pagan and Julio Martinez. Project Return also op- Non-Residential Care was developed to provide erates a women’s and children’s treatment center, community-based transitional services to young- allowing children to remain with addicted mothers sters returning to Philadelphia after placement in during treatment. state institutions. The success of this project led to Under the leadership of president Jane Velez the its expansion to Pittsburgh. Inspired by the Non- agency diversified significantly. Project Return also Residential Care model, Supervised Home Services operates an outreach, anti-AIDS education/preven- was developed later that year as a nonresidential tion program, a medically supervised, drug-free reentry service for youngsters returning to Phila- outpatient program, and a modified TC-oriented delphia from Abraxas’s residential programs. health-related, facility for substance abusers who Education has been an integral part of the phi- are HIV and symptomatic. The latter service is losophy of treatment since Abraxas’s inception. administered jointly by Project Return Foundation, The Abraxas School, a private high school on the Inc., Samaritan Village, and H.E.L.P., Inc. In total, Abraxas I treatment campus, offers a full curricu- nearly 1,000 men and women receive daily treat- lum of courses and special educational services for ment and rehabilitative services through programs the resident population. Alternative schools have administered by Project Return Foundation, Inc. been developed in Erie and Pittsburgh in recogni- All of Project Return’s RDF TC programs are run tion of the tremendous difficulty troubled adoles- according to the same clinical principles—they pro- cents have returning to public high schools. vide comprehensive, holistic, individualized treat- Abraxas has also extended its programming to in- ment and rehabilitative services to the residents clude families of origin: The Abraxas Family Asso- through interdisciplinary treatment teams. Inter- ciation meets in chapters throughout Pennsylvania disciplinary teamwork spans the entire length of and West Virginia to offer education, group coun- stay in the TC programs, from admissions to seling, intervention, and referral work to the fami- discharge. lies of clients.

ABRAXAS INSTITUTE ON BLACK CHEMICAL ABUSE (IBCA) The Abraxas Foundation was started in Penn- sylvania in 1973, in response to Requests for Pro- Founded in 1975, the Institute on Black Chemi- posals (RFP) from the Governor’s Council on Drug cal Abuse (2616 Nicollet Avenue S, Minneapolis, TREATMENT PROGRAMS, CENTERS, AND ORGANIZATIONS: AN HISTORICAL PERSPECTIVE 1139

MN 55408; 612-871-7878) is an open-member- In addition to conducting retreats and support ship organization that provides culturally specific programs, JACS provides community outreach programs and client services for the African-Ameri- programs. These programs disseminate informa- can community. IBCA defines cultural specificity as tion to educate and sensitize Jewish spiritual lead- the creation of an environment that encourages and ers, health professionals, and the Jewish commu- supports the exploration, recognition, and accep- nity about alcoholism and substance abuse, and tance of African-American identity and experience, about the effects of ALCOHOLISM and drug depen- including the unique history associated with being dence on Jewish family life. African American in the United States and the role that racial identity plays in drug dependence. Pro- SOCIETY OF AMERICANS FOR grams are designed to address the devastating ef- RECOVERY (SOAR) fects of the drug-abuse problem on this community. Services are provided in assessment and Society of Americans for Recovery (600 E. 14th intervention for outpatient treatment and after- Street, Des Moines, IA 50316; 515-265-7413) was care, black co-dependency issues, home-based sup- founded by Harold E. Hughes, a former governor port, and for pregnant women and young children. and senator from Iowa. It is a national grass-roots IBCA’s efforts in the community provide train- organization of concerned people whose aim is to ing and prevention resources to educate those who prevent and treat dependence on alcohol and other face the problems of substance abuse. The Techni- drugs, and to educate the public about substance cal Assistance Center (TAC) offers training work- abuse and about its successful treatment. The orga- shops, program consultation, and resource materi- nization sponsors regional conferences throughout als on African Americans and substance abuse. the country and publishes a newsletter. TAC also educates and trains clergy members The organization lobbies to fight the stigma that working with these issues in the community. The society places on alcoholics and addicts, and it ad- IBCA prevention programs have involved school vocates and lobbies for more and better treatment. and business leaders in social-policy programs It also encourages people to learn more about ad- aimed at establishing community awareness of sub- dictions and recovery and to meet others who are stance-abuse issues; the Drug Free Zones program, active in communities on behalf of substance-abuse in particular, has received national recognition. issues.

JEWISH ALCOHOLICS, CHEMICALLY BETTY FORD CENTER DEPENDENT PERSONS AND This eighty-bed hospital for recovery from SIGNIFICANT OTHERS FOUNDATION, chemical dependency was named in honor of Presi- INC. (JACS) dent Gerald Ford’s wife, who was treated success- JACS is a nonprofit, tax-exempt, volunteer fully and who promotes such therapy. The center is membership organization located at 850 Seventh located southeast of Palm Springs, California, on Avenue, NewYork, NY 10019; 212-397-4197. the campus of the Eisenhower Medical Center. JACS was established as a result of work done by The staff at the center views ALCOHOLISM and the Task Force on Alcoholism and Substance Abuse other drug dependencies as chronic progressive dis- of the Federation of Jewish Philanthropies of New eases that will be fatal if they are not treated. The York (UJA-Federation). program at Betty Ford is designed so that patients JACS provides support programs and conducts learn to become responsible for their own actions retreats enabling recovering Jewish substance and recovery. Because chemical dependency affects abusers and their families to enhance family com- the family unit, the center has created the family- munication, and reconnect with Jewish traditions treatment program, a five-day intensive process and spirituality. The programs are designed to help that includes education and individual and group participants find ways in which Judaism can assist therapy. The center’s staff also addresses the fact their continuing recovery. Participants and rabbis that women have traditionally been hidden chemi- explore the relationship between Jewish spiritual cally dependent people, so their treatments for concepts and TWELVE-STEP PROGRAMS. women differ from those for men. 1140 TREATMENT

(SEE ALSO: Alcohol- and Drug-Free Housing; Am- MCELRATH, D. (1987). Hazelden: A spiritual odyssey. phetamine Epidemics; Appendix III, Volume 4: Center City, MN: Hazelden Educational Services. State-by-State Treatment and Prevention Pro- NEBELKOPF, E. (1986). The therapeutic community and grams; Association for Medical Education and Re- human services in the 1980s. Journal of Psychoactive search in Substance Abuse; Civil Commitment; Drugs, 18(3), 283–286. Coerced Treatment; Ethnic and Cultural Relevance NEBELKOPF, E. (1987). Herbal therapy in the treatment in Treatment; Ethnicity and Drugs; Halfway of drug use. International Journal of the Addictions, Houses; Jews, Drugs, and Alcohol; Lysergic Acid 22(8), 695–717. Diethylamide; Pregnancy and Drug Dependence; NEBELKOPF, E. (1989). Innovations in drug treatment Prevention Movement; Prisons and Jails: Drug and the therapeutic community. International Jour- Treatment in; Sobriety; Substance Abuse and nal of Therapeutic Communities, 10(1), 37–49. AIDS; Treatment/Treatment Types; Treatment Al- PERRY, C. (1984). The Haight-Ashbury: A history. New ternatives to Street Crime; Treatment, History of; York: Random House. Treatment In the Federal Prison System; Vulnera- SEYMOUR, R. B., & SMITH, D. E. (1986). The Haight- bility as Cause of Substance Abuse: Race; Vulnera- Ashbury Free Clinics: Still free after all these years. bility as Cause of Substance Abuse: Sexual and Sausalito: Westwind Associates. Physical Abuse) SMITH, D. E., & LUCE,J.Love needs care. Boston: Little, Brown. SORENSEN, J., ACAMPORA, A., & ISCOFF, D. (1984). From BIBLIOGRAPHY maintenance to abstinence in the therapeutic commu- ACAMPORA, A., & NEBELKOPF, E. (1986). Bridging ser- nity: Clinical treatment methods. Journal of Psycho- vices: Proceedings of the Ninth World Conference of active Drugs, 16(3), 229–239. Therapeutic Communities. San Francisco: World SORENSEN, J., DEITCH D.,&ACAMPORA, A. (1984). Treat- Federation of Therapeutic Communities. ment collaboration of methadone maintenance pro- ACAMPORA, A., & STERN, C. (1992). Evolution of the grams and therapeutic communities. American Jour- therapeutic community. In Drugs & society: Proceed- nal of Drug and Alcohol Abuse, 10(3), 347–359. ings of the Fourteenth World Conference of Therapeu- ALFONSO ACAMPORA tic Communities. Montreal: World Federation of ARLENE R. LISSNER Therapeutic Communities. DANIEL S. HEIT BETTY FORD CENTER. (1994). Brochure. Palm Springs, DAVID A. DEITCH CA: Author. DAVID E. SMITH CARROLL, J. F. X. (1992). The evolving American thera- DAVID J. MACTAS peutic community. Alcoholism Treatment Quarterly, ETHAN NEBELKOPF 9(3/4). 175–181. FAITH K. JAFFE DEITCH, D. A. (1973). Treatment of drug abuse in the J. CLARK LAUNDERGAN therapeutic community: Historical influences, current JANE VELEZ considerations and future outlook. In National Com- JEROME F. X. CARROLL mission on Marihuana and Drug Abuse. Report to JEROME H. JAFFE Congress and the President, vol. 5. Washington, DC: JOHN NEWMEYER U.S. Government Printing Office. KEVIN MCENEANEY DELEON, G. (1984). The therapeutic community: Study RICHARD B. SEYMOUR of effectiveness. National Institute on Drug Abuse. ROBIN SOLIT Treatment Research Monograph Series, DHHS Pub. RONALD R. WATSON No. (ADM) 84-1286. Washington, DC. SHIRLEY COLETTI FALCO, M. (1992). The making of a drug-free America: SIDNEY SHANKMAN Programs that work. NewYork: Times Books. LAUNDERGAN, J. C. (1982). Easy does it: Alcoholism treatment outcomes, Hazelden and the Minnesota TREATMENT The following series of arti- Model. Center City, MN: Hazelden Educational Ser- cles provides the reader with brief descriptions of vices. some of the diverse ways that people with sub- TREATMENT: Alcohol Abuse: 2000 and Beyond 1141 stance-related problems can be helped. It is orga- Polydrug Abuse, An Overview; nized into two subsections. Treatment consists of Polydrug Abuse, Pharmacotherapy; summaries of the common ways that problems re- Tobacco, An Overview; lating to specific substances are currently treated. Tobacco, Pharmacotherapy; Different approaches are described for alcohol, co- Tobacco, Psychological Approaches; caine, heroin, polydrug abuse, and tobacco. Treat- Twelve Step Facilitation (TSF). ment Types presents descriptions of distinct interventions that are applicable to dependence on a variety of drugs. Alcohol Abuse: 2000 and Beyond Every In practice, many treatment programs are hy- day, more than 700,000 people in the United States brids, incorporating features from several distinct receive treatment for problems with alcohol use. treatment modalities and adapting them to specific Treatment can be behavioral therapy, or behav- needs having to do with age, gender, ethnic, racial, ioral therapy in combination with medication. New and socioeconomic factors, provider preference, therapies will likely take advantage of findings and the economic realities that govern delivery of from neuroscience about alcohol’s effects in the treatment. brain and include medications targeted at specific Neither of the sections is exhaustive. A variety of sites in the brain involved in the development of substance dependence interventions employed in alcohol use problems. other countries and by certain ethnic groups in the United States (such as sweat lodges among some BEHAVIORAL THERAPY AND Native American tribes) are not covered. Neverthe- ALCOHOLISIM TREATMENT less, the entries included here should allowthe reader to become reasonably familiar with what is A broad range of psychological therapies cur- considered mainstream treatment in the United rently are used to treat alcoholism. Many of these States at the turn of the millennium. therapies have been in use for some thirty years. Others are more recent developments. Many older TREATMENT treatments for alcoholism were developed before modern standards of evaluating treatment out- This section contains summaries of the common comes were accepted in the alcohol field. Thus, the ways that problems relating to specific substances various approaches to treating alcoholism have dif- are currently treated. It is organized first by drug ferent levels of scientific support for the effective- and then by treatment approach. Different ap- ness. Treatments that have been evaluated include proaches are described for Alcohol, Cocaine, Her- client-treatment matching and professional treat- oin, Polydrug Abuse, and Tobacco. The reader ments modeled on the twelve steps of Alcoholics should also see the entries for each of these topics Anonymous. Newer treatments that have been de- and the entries for Barbiturates, Inhalants, and veloped and evaluated include brief or minimal in- Nicotine under their individual headings, and the tervention, motivation enhancement therapy, and section belowentitled Treatment Types. cognitive-behavioral therapy. This section contains the following articles: Brief or Minimal Intervention. One in five Alcohol Abuse: 2000 and Beyond; men and one in ten women who visit their primary Alcohol, An Overview; care providers are at-risk drinkers or alcohol-de- Alcohol, Behavioral Approaches; pendent. Brief intervention, which is designed to be Alcohol, Pharmacotherapy; conducted by health professionals who do not spe- Cocaine, An Overview; cialize in addictions treatment, can help at-risk Cocaine, Behavioral Approaches; drinkers to decrease their risk and to motivate Cocaine, Pharmacotherapy; alcohol-dependent patients to enter formal alcohol- Drug Abuse: 2000 and Beyond; ism treatment. The main elements of brief inter- Heroin, Behavioral Approaches; vention can be summarized by the acronym Heroin, Pharmacotherapy; FRAMES: feedback, responsibility, advice, menu Marijuana, An Overview; of strategies, empathy, and self-efficacy. Although 1142 TREATMENT: Alcohol Abuse: 2000 and Beyond research has shown that brief interventions can be tended to duplicate or substitute for tradi- effective it has not yet been widely implemented. tional AA.) Patient-Treatment Matching. Patient-treatment matching is using a patient’s individual char- No decisive matches between patients and treat- acteristics (such as gender, anger level, social func- ments were found; the three treatments were ap- tioning, and severity of alcohol dependence) to proximately equal in their efficacy for all patients. select an appropriate treatment therapy. A com- Further, treatment in all three approaches resulted monly held viewin alcoholism treatment is that in substantial, long-term reductions in drinking matching patients to treatments will improve treat- and related problems. Twelve-step Programs. ment outcome. This viewwassupported by thirty Professional Treat- small-scale research studies conducted during the ment based on the twelve steps of AA is the domi- 1980s that found a variety of matching effects. A nant approach to alcoholism treatment in the large multi-site clinical trial, Matching Alcoholism United States. Higher levels of AA attendance dur- Treatments to Client Heterogeneity (Project ing and following professional treatment are con- MATCH), was initiated in 1989 to rigorously test sistently associated with better outcomes, but AA the most promising hypothetical matches. Patients affiliation without professional treatment has not were randomly assigned to one of the following routinely resulted in improvement. Twelve-step three different types of behavioral therapy: approaches also have been found to be more effective than motivational enhancement therapy for Motivational Enhancement Therapy (MET), a individuals whose social networks support drink- brief intervention using techniques of mo- ing. tivational psychology to encourage indi- Medications for Alcoholism Treatment. viduals to consider their situation and the One of the major changes in alcoholism treatment effect of alcohol on their life, to develop a is the current and future availability of medications plan to stop drinking, and to implement that can improve treatment outcome. Medications the plan. that interfere with craving can reduce the likeli- Cognitive -Behavioral Skills Therapy (CBST) hood that a recovering alcoholic will suffer a rein which alcoholism is viewed as a type of lapse. Two such medications are currently avail- maladaptive, learned, behavioral re- able: naltrexone in the United States and sponse to stressful triggers. In CBST, the acamprosate in Europe. A third medication, patient is taught ways to respond to nalmefene, is currently under study. drinking-provoking situations with non- Naltrexone. Naltrexone is the first medication ap- drinking actions. Patients practiced proved to help maintain sobriety after detoxifica- drink-refusal skills, learned to manage tion from alcohol since the approval of disulfiram negative moods, and learned to cope with (Antabuse ) in 1949. Originally developed for use urges to drink. in treating heroin addicts by reducing their Twelve-step Facilitation Therapy (TSF), cravings for this drug, naltrexone was observed to which encouraged patients to become in- reduce alcohol use by heroin addicts. Further revolved in Alcoholics Anonymous (AA). In search confirmed this observation: naltrexone used TSF, trained therapists helped patients to in combination with verbal therapy prevented re- find AA sponsors, arranged for regular AA lapse more than standard verbal therapy alone. attendance, introduced patients to AA lit- Acamprosate. Acamprosate was developed in Eu- erature and other materials, and helped rope. Clinical trials are nowunderwayin the patients to work the first five of AA’s United States to gain approval by the FDA to mar- twelve steps. (TSF was designed specifi- ket acamprosate in the United States. The results of cally for Project MATCH. Although the European clinical trials of acamprosate were grounded in the twelve-Step principles, it very similar to those found in the U.S. with naltrex- was a professionally delivered, individual one; about twice as many people did well with therapy different from the usual peer-or- acamprosate as they did with placebo. They also ganized AA meetings and was not in- found, as with naltrexone, that the medication is TREATMENT: Alcohol, An Overview 1143 effective only in combination with behavioral ther- Alcohol, An Overview Alcohol abuse and apy. ALCOHOLISM are serious problems. Alcohol abuse Nalmefene. A newopiate antagonist—nalmefene— refers to heavy, problematic drinking by has recently been tested for use in alcoholism treat- nondependent persons, while alcoholism suggests ment. This medication significantly reduced re- TOLERANCE,PHYSICAL DEPENDENCE, and impaired lapse to heavy drinking among recovering alcohol- control of drinking. There are an estimated 9 mil- ics, decreased the risk of relapse, and produced no lion alcohol-dependent persons and 6 million alco- significant side effects. In studies in which naltrex- hol abusers in the United States (Williams et al., one and nalmefene were compared, nalmefene en- 1989). tered the bloodstream more quickly and had a Problems that arise from misuse of alcohol vary somewhat lower risk of liver toxicity than did nal- widely, but they often include the following areas: trexone. financial, legal, family, employment, social, and medical. Medical complications include alcoholic Combined Therapeutic Approaches. Com- liver disease, gastritis, pancreatitis, organic brain bining behavioral therapies with phar- syndrome, and the FETAL ALCOHOL SYNDROME macotherapies is likely to be the next important (FAS). It is estimated that more than 100,000 advance in alcoholism treatment. There are several alcohol-related deaths occurred in the United ways in which behavioral and pharmacological States in 1987 (Centers for Disease Control, 1990). therapies could work together: One therapy might The most common alcohol-related death is a motor continue to function if the other failed; each ther- vehicle fatality. apy might increase the effectiveness of the other; or Despite the complex nature of alcohol abuse and each might act on the same neural circuits. Naltrex- dependence, research has burgeoned over the past one, used in combination with behavioral therapy, decade and has deepened our understanding of the has been shown to prevent relapse more than be- causes, prevention, and remediation of alcohol havioral therapy alone. The effectiveness of com- abuse and alcoholism. Here, we briefly review as- bined therapeutic approaches, including ap- sessment of alcohol problems, detoxification, and proaches which combine both acamprosate and treatment. naltrexone, are currently being examined. ALCOHOLISM ASSESSMENT BIBLIOGRAPHY To appropriately assign an individual to treat- NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOL- ment, his or her condition must be accurately eval- ISM. (2000). Tenth special report to the U.S. Congress uated. Management of alcoholism may be seen as on alcohol and health. National Institutes of Health involving a five-stage sequential process: screening, Publication No. 00-1583. Bethesda, MD: National In- diagnosis, triage, treatment planning, and treat- stitutes of Health. ment-outcome monitoring. Specific procedures exist to help inform clinical decisions at each of these NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOL- stages (Allen, 1991). Screening tests help deter- ISM. (1995). The physicians’ guide to helping patients mine whether a drinking problem might exist. If with alcohol problems. NIH Pub. No. 95-3769. Be- this seems likely, formal and more lengthy diagnos- thesda, MD: National Institutes of Health. tic procedures are performed to specify the nature NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOL- of the problem. If the diagnosis of alcoholism is ISM. (1999). Alcohol alert no. 43, brief intervention established, determination of the type of treatment for alcohol problems. Bethesda, MD: National Insti- setting and intensity of care needed for detoxifying tutes of Health. and treating the patient must be made next. Treat- NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOL- ment planning can then be initiated to establish ISM. (1997). Alcohol alert no. 36, patient-treatment rehabilitation goals and strategies appropriate to matching. Bethesda, MD: National Institutes of the patient. Finally, outcome is monitored to deter- Health. mine if further treatment is needed or if a different ENOCH GORDIS treatment approach is advisable. 1144 TREATMENT: Alcohol, An Overview

DETOXIFICATION them. Other medications to treat withdrawal include beta-adrenergic blockers, alpha-2 adrenergic When an alcohol-dependent person abruptly agonists, calcium channel blockers, and anticon- stops drinking, physiological symptoms may occur. vulsant agents such as carbamazepine; however, This cluster of symptoms is termed alcohol with- the first two categories of drugs do not prevent drawal, and symptoms can range from relatively seizures and, therefore, are less useful than benzo- mild discomfort to life-threatening problems. Mild diazepines. Recent research suggests that carbam- symptoms include sweating, tachycardia (rapid azepine may be an effective alternative to benzodi- heartbeat), hypertension, tremors, anorexia, azepines, while calcium channel blockers are still in sleeplessness, agitation, and anxiety. More serious early stages of research. consequences involve seizures and, rarely, DELIR- IUM TREMENS (DTs), characterized by agitation, hyperactivity of the autonomic nervous system, dis- TREATMENT OPTIONS orientation, confusion, and auditory or visual hal- After screening, diagnosing, and detoxifying a lucinations. It has been postulated that as the num- patient, the clinical staff has numerous options for ber of untreated withdrawal episodes increases, the short- and long-term treatment. While a more de- potential for more serious symptoms in subsequent tailed reviewof these interventions can be found in withdrawals may also escalate. This phenomenon is Hester and Miller (1989), the techniques can be known as kindling (Brown, Anton, Malcolm & categorized as follows: Ballenger, 1988). Alcoholics Anonymous. Since the 1940s, AL- Treatment of alcohol withdrawal includes both COHOLICS ANONYMOUS (AA) has been an important pharmacological and nonpharmacological inter- component of alcoholism rehabilitation, and many ventions. It is generally believed that if the with- recovered alcoholics are convinced that AA was drawal symptoms are mild to moderate, no medica- essential for their recovery. As a means of achieving tions are needed. Instruments such as the Clinical and maintaining SOBRIETY, AA consists of regular Institute Withdrawal Assessment Scale (Foy, meetings utilizing fellowship, mutual support for March & Drinkwater, 1988) have recently been sobriety, open discussions, and a program known developed to gauge severity of withdrawal symp- as the TWELVE STEPS. The effectiveness of AA has toms. Nonpharmacological techniques used to treat not been established by randomized clinical trials, milder forms of alcohol withdrawal include efforts largely because the organization was developed to reduce anxiety and to provide emotional reassur- outside the scientific mainstream. A well-designed ance. Patients in withdrawal should receive the B study by Walsh, Hingson, and their colleagues vitamin thiamine so as to prevent the occurrence of (1991) was, however, done in the setting of an EM- the WERNICKE—Korsakoff syndrome, a serious PLOYEE ASSISTANCE PROGRAM (EAP). Employees neurological complication of alcoholism. seeking or referred for treatment were randomly If the symptoms are more severe, however, drugs assigned to inpatient treatment with AA as a com- should be prescribed. The most commonly used ponent, AA alone, or self-choice of treatment. All medications to treat withdrawal have been three treatment conditions resulted in equal im- BENZODIAZEPINES. The benzodiazepines have been provement in job performance; however, inpatient demonstrated in randomized clinical trials to re- treatment did better than AA or self-choice in terms duce the occurrence of seizures and other serious of several aspects of drinking behavior. Inpatient withdrawal symptoms. They have a wide margin of treatment was particularly valuable for those em- safety. Side effects, however, include transient ployees who were abusing both alcohol and CO- memory impairment, drowsiness, lethargy, and CAINE. Other self-help groups that do not use the motor impairment. Benzodiazepines must be ta- twelve-step program (e.g., RATIONAL RECOVERY) pered down and then stopped after the patient is no also exist. longer suffering from withdrawal because patients Minnesota Model. The MINNESOTA MODEL is can develop dependence on them. In addition, the so named because it originated in several alcohol- physiological effects of benzodiazepines are syner- ism programs in Minnesota and is the most com- gistic or additive with those of alcohol—hence, it is mon type of inpatient treatment for alcoholism in important that patients not drink while taking the United States. It stresses complete abstinence TREATMENT: Alcohol, An Overview 1145 and employs methods such as group and individual uations that may serve as high-risk drinking stim- therapy, alcohol education, family counseling, and uli. Relapse prevention is important in alcoholism required attendance at AA meetings. The staff in treatment, since many patients who are success- these programs are usually a mixture of profes- fully detoxified and stabilized tend to revert to sional individuals and recovering alcoholics. The drinking. While relapse prevention is widely used, evidence for its effectiveness is limited. The study the evidence of its effectiveness is again limited, by Walsh et al. (1991) supports the idea that these albeit promising. programs are effective. Studies on health-care utili- Stress Management. Stress-management zation costs before and after treatment for alcohol- techniques may be employed to reduce emotional ism also add evidence that these programs are ef- discomfort, which may contribute to drinking be- fective. When this general program is used to treat havior. Specific techniques include deep-muscle re- drug problems other than alcoholism, it is often laxation, biofeedback, systematic desensitization, referred to as a chemical-dependency program. and cognitive and behavioral strategies to cope Group Psychotherapy. Group psychotherapy with stress-inducing stimuli. is widely used in the treatment of alcoholics. The Pharmacotherapy. Since the 1950s, DI- many types of group psychotherapy employ sup- SULFIRAM (Antabuse) has been the most widely portive, cognitive, psychoanalytic, or confronta- used medication in the treatment of alcoholism. tional techniques. Also, group psychotherapy is of- Patients on disulfiram are deterred from drinking ten used in conjunction with other approaches, because to do so would cause physical discomfort, such as AA and pharmacologic adjuncts to treat- including headaches, flushing, and rapid heartbeat. ments. A major problem in using disulfiram is lack of Individual Psychotherapy. Individual psy- patient compliance. Several techniques have been chotherapy attempts to probe possible underlying developed to enhance compliance, including estab- reasons for problem drinking and subsequently lishing a contract with the client or significant other strives to guide the patient in working through on disulfiram administration, offering positive and emotional difficulties. Some of the cognitive and negative incentives for taking the medication, and behavioral approaches described belowcan also be using implants. considered forms of psychotherapy. Similar to In addition to disulfiram, recent advances have group psychotherapy, individual psychotherapy is been made in the development of medications that often combined with other treatment activities. De- directly curb desire to drink. The most promising spite the widespread use of group and individual include serotonergic agents and opioid antago- psychotherapy, the scientific evidence supporting nists—these agents act on brain mechanisms that their efficacy as isolated treatments is limited. are believed to be related directly to drinking. Family and Marital Therapy. This type of Aversive Therapy. This type of therapy at- therapy involves the problem drinker, spouse, and tempts to establish a conditioned avoidance re- sometimes other family members. Over the past sponse to alcohol. Drinking is paired with unpleas- several years, research interest has heightened in ant experiences, such as electric shock, nausea, determining the contribution of family and marital vomiting, or imagined unpleasant consequences. factors in aiding the patient to sustain recovery. The underlying rationale of AVERSION conditioning Generally, family and marital therapy seeks to en- is that patients will be less likely to drink if they hance communication, problem-solving, and posi- associated alcohol consumption with immediate tive reinforcement skills. negative consequences. Good evidence that this ap- Social-Skills Training. Social-skills training proach is effective is lacking, because of the ab- includes techniques for improving communication sence of randomized clinical trials evaluating aver- skills, forming and maintaining interpersonal rela- sive therapy. Some programs using it report very tionships, resisting peer pressure for drinking, and high levels of abstinence, however, in the months becoming more assertive. Research on its effective- following inhospital treatment. ness has been encouraging. Patient-Treatment Matching. A newer strat- Relapse Prevention. RELAPSE PREVENTION is egy in alcoholism treatment attempts to match par- a behavioral approach that deals with teaching the ticular types of treatments to relevant patient char- patient to successfully cope with environmental sit- acteristics, rather than assigning all patients to 1146 TREATMENT: Alcohol, Behavioral Approaches

similar treatments. Common patient-matching BROWN, M. E., ET AL. (1988). Alcohol detoxification and variables include the patient’s collateral psychopa- withdrawal seizures: Clinical support for a kindling thology, degree of alcohol involvement, and per- hypothesis. Biological Psychiatry, 23, 507–514. sonality and motivational characteristics. Approxi- CENTERS FOR DISEASE CONTROL. (1990). Alcohol-related mately forty studies, although based on small mortality and years of potential life lost—United numbers of patients, have supported the concept States, 1987. Morbidity and Mortality Weekly Report, that patient-treatment matching improves treat- 39(11), 173–175. ment outcome. FOY, A., MARCH, S., & DRINKWATER, V. (1988). Use of an Community-Reinforcement Approach. The objective clinical scale in the assessment and manage- community-reinforcement approach (CRA) is a ment of alcohol withdrawal in a large general hospi- broad-spectrum treatment approach that focuses tal. Alcohol: Clinical and Experimental Research, on positive reinforcers for abstinence in the pa- 12(3), 360–364. tient’s natural environment. Specific techniques in- HESTER,R.K.,&MILLER,W.R.(EDS.). (1989). Hand- clude adding improvements to the patient’s em- book of alcoholism treatment approaches: Effective ployment conditions, marital relationships, alternatives. NewYork: Pergamon. problem-solving skills, social skills, and stress WALSH, D. C., ET AL. (1991). A randomized trial of treat- management—and different components of the ment options for alcohol-abusing workers. New En- program are chosen for the individual, depending gland Journal of Medicine, 325, 775–782. on his or her life problems. The initial studies of WILLIAMS, G. D., ET AL. (1989). Epidemiologic Bulletin CRA are encouraging. no. 23: Population projections using DSM-III criteria. Alcohol Health and Research World, 13(4), 366– 370. CONCLUSIONS RICHARD K. FULLER Advances in treatment research have led to a JOHN P. ALLEN variety of treatment interventions. The alcoholism- RAYE Z. LITTEN treatment community must become better able to assist the recovery of alcoholics and alcohol abusers. Advances in assessment technology have Alcohol, Behavioral Approaches The helped identify patient needs more clearly; this use of behavioral and other psychological treat- subsequently enables the clinician to provide a ments for alcohol abuse has a long history. In the treatment regime tailored to the needs of the pa- nineteenth century, Benjamin Rush, often regarded tient. An important future direction for alcoholism- as the founder of American psychiatry, described a treatment research is to discover howto more pre- variety of social and psychological cures for chronic cisely match patients with specific types of treat- drunkenness. Treatment procedures derived from ment interventions. Also, development of newmed- principles of learning and conditioning were being ications to directly reduce drinking behavior will tested in the 1920s, prior to the development of have a major impact. Future treatments will likely modern pharmacologic approaches. Currently, combine pharmacologic interventions with behav- there is a large scientific literature documenting the ioral and psychosocial therapies to further improve effectiveness of various behavioral treatments for treatment outcome. alcohol problems. The most obvious argument for the use of be- (SEE ALSO: Accidents and Injuries from Alcohol; havioral approaches in treating alcohol abuse is Complications; Treatment, History of; Treatment that the drinking of alcohol or ethyl alcohol is a Types) behavior. Regardless of the therapeutic approach used, the criterion for success or failure in treatment studies is typically behavioral—whether and BIBLIOGRAPHY howmuch a person continues to drink. Research ALLEN, J. P. (1991). The interrelationship of alcoholism amply demonstrates that drinking behavior is sub- assessment and treatment. Alcohol Health and Re- stantially influenced by a wide variety of psycho- search World, 15, 178–185. logical processes, including beliefs and EXPECTAN- TREATMENT: Alcohol, Behavioral Approaches 1147

CIES, the examples of friends and family, the alcohol use to a level that will no longer threaten a customs and norms for drinking within one’s soci- person’s physical or psychological health. The goals ety or subgroup, emotional states, family processes, of treatment may also include other important di- and the positive and negative consequences of mensions besides drinking—to get and hold a job, drinking. Treatments that address these factors di- to have a happier marriage and family life, to learn rectly, then, might be expected to be helpful in how to deal with anger, and to find new ways of overcoming alcohol problems. having fun that do not involve drinking. Finally, it In fact, dozens of well-controlled studies since is worth noting that clients may have treatment the 1960s do support the effectiveness of behav- goals that differ from those of the therapist. Behav- ioral treatments. The benefits of such treatment ioral treatment methods do not inherently dictate have typically been larger than those reported for outcome goals, but they can be used to achieve pharmacologic approaches and have been shown in goals once chosen. some studies to endure over follow-up periods of Teaching New Skills. Alcohol is often used in several years. This research in itself provides a an attempt to cope with life problems. People may convincing reason to use behavioral methods in drink to relax or loosen up, to get to sleep, to feel treating alcohol abuse. better, to enhance sexuality, to build courage, or to Still another reason is the finding that psychoso- forget. In truth, alcohol rarely works as an effective cial processes strongly influence whether or not a coping strategy for dealing with emotional and person will relapse after treatment. The likelihood relationship problems. In the long run, it often of relapse is decreased by factors such as marital makes such problems worse. Yet the seeming im- stability, social support, personal coping skills, em- mediate relief can make alcohol appealing when a ployment, and confidence in one’s abilities to deal person is faced with bad feelings or social prob- with problems. Factors like these in a person’s life lems. To the extent that a person comes to rely after treatment are important determinants of out- upon drinking to cope, that person is termed psy- come. Treatment methods that anticipate and ad- chologically dependent on alcohol. dress these post-treatment adjustment challenges One behavioral approach, sometimes called are thus important. broad-spectrum treatment, directly addresses this There is, however, little reason to argue for be- problem by teaching the person newcoping skills. havioral versus pharmacological treatment ap- Ten controlled studies, for example, have found proaches, since these two approaches can be used that the addition of social-skills training increases together with good result. Behavioral methods play the effectiveness of treatment for alcohol abuse. a key role in addressing psychosocial aspects of People are taught skills for expressing their feelings drinking problems and are compatible with the use appropriately, making requests, refusing drinks, of medications, where they are appropriate. and carrying on rewarding conversations. Stress- management training has also been shown to help prevent relapse to drinking. People learn howto ALTERNATIVE BEHAVIORAL relax and deal with stressful life situations without METHODS using drugs. A behavioral approach to treating alcohol abuse Self-Control Training. Another well-docu- does not involve just one method. Rather, a variety mented behavioral approach is self-control train- of strategies can be used to accomplish the central ing, which teaches methods for managing one’s goal—to change drinking behavior—and several own behavior. Some common elements in self-con- methods are typically employed in a treatment pro- trol training include: (1) setting clear goals for be- gram. havior change; (2) keeping records of drinking be- Treatment methods should not be confused with havior and urges to drink; (3) rewarding oneself for treatment goals. The general behavioral methods progress toward goals; (4) making changes in the described belowcan be applied in pursuit of differ- way one drinks, or in the environment, to support ent goals. Sometimes the goal of treatment is the newpatterns; (5) discovering high-risk situations complete elimination of alcohol drinking for the where extra caution is required; and (6) learning rest of a person’s lifetime (total and permanent strategies for coping with high-risk situations. Al- abstinence). For others, the goal may be to reduce though often used to help people reduce their 1148 TREATMENT: Alcohol, Behavioral Approaches drinking to a moderate and nonproblematic level, poor track record in treatment-outcome studies. As self-control training can also be used when total a distinct element, confrontational group therapy, a abstinence is the goal. This method has been found common element of U.S. treatment programs, is to be particularly helpful for less severe problem also unsupported by current research. More re- drinkers. It has also been found to be more effective cently, cognitive therapies have gained popularity, than educational lectures for drunk-driving of- and some controlled trials supporting their efficacy. fenders. Changing the Environment. Yet another be- Marital Therapy. There are several reasons to havioral approach is behavior modification by consider treating not only the excessive drinker, but changing the consequences of drinking. The goal also the spouse. First, problem drinking commonly here is to eliminate positive reinforcement for affects the drinker’s partner in adverse ways. Sec- drinking, and to make alternatives to drinking ondly, the spouse may be quite helpful during more rewarding. Studies have reported success in treatment in clarifying the problem and in develop- working unilaterally with a drinker’s spouse to ing effective strategies for change. Thirdly, the make changes that discourage drinking and rein- spouse can provide continuing support for change force alternatives. A complex treatment known as after treatment. Finally, marital distress may be a the community-reinforcement approach (CRA) has significant factor in problem drinking, and direct fared well in comparisons with traditional methods. treatment of marital problems can help to prevent The CRA systematically encourages rewarding al- relapse. ternatives to drinking, teaching skills needed for Research indicates that problem drinkers living without alcohol. The CRA incorporates a treated together with a spouse fare better than number of treatment elements, including marital those treated individually. Behavioral marital ther- therapy, social-skills training, the taking of di- apy in particular is well supported by current out- sulfiram (Antabuse—a medication that causes come research. aversive effects when alcohol is ingested), and job- Aversion Therapies. Another set of treatment finding training. The use of behavioral contrac- strategies applies the learning principle of aversive ting—drawing up a specific agreement about fu- counterconditioning (called AVERSION THERAPY). ture drinking and its consequences—has been The idea here is that if drinking is paired with found to be an effective component of treatment in unpleasant images and experiences, the desire for several studies. alcohol is diminished, and drinking decreases. Brief Motivational Counseling. An interest- There is sound evidence that it is possible to pro- ing and unexpected finding in more than a dozen duce a conditioned aversion to alcohol in both ani- well-controlled studies is the effectiveness of rela- mals and humans. The taste and even thought of tively brief motivational counseling. Certain treat- alcohol become unpleasant. There is also evidence ments, consisting of one to three sessions, have that aversion therapy is successful to the extent that been found to be significantly more effective than this kind of conditioned aversion is established dur- no treatment and often as effective as more exten- ing treatment. Some forms of aversion therapy pair sive treatment regimens. These motivational ap- the taste of alcohol with unpleasant sensations such proaches, nowstudied in several nations, typically as nausea, foul odors, or electric shock. A newer include a thorough assessment, feedback of find- form, termed covert sensitization, uses no physical ings, clear advice to change, and an emphasis on aversion of this kind but instead pairs alcohol with personal responsibility and optimism. The key unpleasant experiences in imagination. These ap- seems to be to trigger a decision and commitment to proaches may be particularly useful for those who change. Once this motivational hurdle has been continue to experience craving or a strong positive crossed, people frequently proceed to change their attachment to alcohol. drinking on their own without further professional Psychotherapy. Many kinds of psychotherapy assistance. In fact, treatment approaches that pro- have been tried with alcohol abusers. In general, ceed directly into strategies for changing drinking studies suggest that individual psychotherapies may fail because they do not address this motiva- with a goal of insight into unconscious causes of tional prerequisite for change. drinking have been largely unsuccessful. Likewise, Therapist Style. Other recent research indi- group psychodynamic psychotherapies have had a cates that the skills and style of the therapist have TREATMENT: Alcohol, Behavioral Approaches 1149 important effects on treatment outcome. With im- Still another example is the issue of length of pressive consistency, therapist success has been follow-up. Success rates are typically highest linked to an empathic and supportive style, rather within a few weeks or months from the time of than an aggressive and confrontational approach. treatment. A large percentage of relapses occur be- Directive and confrontational tactics tend to elicit tween three and twelve months after treatment. resistance and defensiveness from clients, which in Short follow-up periods, then, overestimate success turn are predictive of a lack of therapeutic change. rates. Longer follow-ups raise the additional prob- It is clear that the same treatment approach can lem of howto deal withlost cases. If one studies have dramatically different outcomes when admin- only those who can be easily found two years later, istered by different therapists. success rates may be inflated. For these reasons, the effectiveness of treatment HOW IS SUCCESS JUDGED? approaches is best judged by accumulating evidence from several properly controlled studies. In one sense, judging the outcome of treatment Conclusions presented above, regarding the effi- would seem simple: Either the person is or is not cacy of different psychological treatment ap- still drinking in a problematic manner. A closer proaches, were drawn on this basis. examination of treatment-outcome research quickly reveals a number of complexities. MATCHING PEOPLE TO TREATMENTS First is the question of the standard against which a treatment is to be judged. Is a ‘‘success’’ It is unlikely that research will ever identify a rate of 60 percent spectacularly good or shameful? single superior treatment for alcohol abuse. Drink- This is decided relative to the expected outcome ing and alcohol-related problems are far too com- without the same treatment. This is why the usual plex. The cause for real optimism is found in the standard for judging effectiveness in medical re- number of different approaches with reasonable search is the controlled trial in which clients are evidence of effectiveness. For a given person, then, randomly assigned to different treatment methods. the chances of eventually finding an effective ap- In the absence of proper controls, one cannot judge proach are good. adequately whether the outcome of a treatment is Recent research indicates that these various better or worse than it would have been without the treatment approaches work best for different kinds special treatment. Evidence from properly con- of people. As such evidence accumulates, it will be increasingly possible to choose optimal treatment trolled trials is more consistent than the results of strategies for people based on their individual char- uncontrolled trials, presenting a clearer picture of acteristics. Treatment systems, therefore, should effectiveness. work toward providing a range of different ap- A second complexity is: What constitutes suc- proaches, rather than offering the same basic treat- cess? When success is defined very conservatively, ment to everyone with alcohol problems. as total abstinence from alcohol (not even one drink) since the end of treatment, lowsuccess rates (SEE ALSO: Causes of Substance Abuse; Disease can be expected. Yet if some drinking is permitted Concept of Alcoholism and Drug Abuse; Treatment among ‘‘successes,’’ it is necessary to define the Types) acceptable limits for howmuch, howoften, and with what consequences. Some studies have reported only a category of ‘‘improved’’ cases without BIBLIOGRAPHY adequate definition. BROWN, S., & LEWIS, V. (1998). The alcoholic family in Once successful outcome is clearly defined, there recovery: A developmental model. NewYork: Guilford is the problem of howto measure it. Should a Press. researcher accept the client’s self-report? Should COX,W.M.(ED.). (1987). Treatment and prevention of friends and family members be interviewed? alcohol problems: A resource manual. Orlando, FL: Should blood, breath, or urine samples be re- Academic Press. quired? If multiple outcome measures are used, HESTER,R.K.,&MILLER,W.R.(EDS.). (1995). Hand- howdoes one decide whichis the truth? book of alcoholism treatment approaches: Effective 1150 TREATMENT: Alcohol, Pharmacotherapy

alternatives, 2nd ed. Needham Heights, MA: Allyn & The first section of this article will describe briefly Bacon. the methodology used to conduct clinical phar- MILKMAN, H. B., & SEDERER,L.I.(EDS.). (1990). Treat- macotherapy studies. ment choices for alcoholism and substance abuse. Lexington, MA: Lexington Books. CONTROLLED CLINICAL TRIALS MILLER, W. R., & ROLLNICK, S. (1991). Motivational interviewing: Preparing people to change addictive be- The method used to determine medication effi- havior. NewYork: Guilford Press. cacy is called the controlled clinical trial. The key components of clinical trials include the following: MONTI, P. M., ET AL. (1989). Treating alcohol dependence. NewYork: Guilford Press. control groups; random assignments of eligible subjects to medication or to control groups; use of WASHTON,A.M.(ED.). (1995). Psychotherapy and substance abuse: A practitioner’s handbook. NewYork: placebos (identically appearing but inactive medi- Guilford Press. cations) for the control group—unless a standard effective medication is available to serve as the WILLIAM R. MILLER comparison; assurance that neither the patients re- REVISED BY ANNE DAVIDSON ceiving the drug nor the physicians administering/ prescribing knowwhetherthey are getting the active medication or the placebo (called double- Alcohol, Pharmacotherapy Research on blind); methods that validly and reproducibly mea- pharmacotherapy for ALCOHOLISM continues to ex- sure the response to the medication; methods to pand, as there are still many questions unanswered monitor whether subjects take the medication; and at the turn of the millennium. Currently, the most procedures to followall the patients whoentered widely used medication for the treatment of alco- the study for the duration of the clinical trial. After holism is DISULFIRAM, which has been in use for the data are collected, they must be analyzed by half a century. Disulfiram (Antabuse ) does not using the appropriate statistical tests. act to reduce the CRAVING for ALCOHOL or amelio- Randomizing. It is important to randomize rate the euphorigenic (feeling of well-being) effect eligible patients to the treatment and placebo of alcohol. A variety of newer drugs were tested in groups, because this assures that the two groups are the late 1990s but have not fulfilled early expecta- comparable except for the medications being pre- tions. It was hoped that ‘‘anticraving’’ medications scribed. If some method other than randomization and medications that reduce the ‘‘high’’ from is used to assign patients to treatments, it is likely drinking alcohol would be particularly useful in that the groups will differ in important characteris- recovering alcoholics who are prone to relapse. tics such as severity of illness. If one of the groups is Medications originally developed to treat DEPRES- in general more severely ill than the other, the SION and ANXIETY were also thought to have poten- sicker group is less likely to do well regardless of the tial for managing drinking behavior in specific treatment. If the more severely ill group receives the subgroups of alcoholics. These also do not appear active medication, the difference between the medi- to be helpful except among some alcoholics with cation group and the placebo group after treatment comorbid psychiatric disorders. does not appear as great because the placebo (con- This article focuses on four categories of medica- trol) group was less ill at the beginning. Thus, it tions that are either currently available or are still may appear that the medication was not effective. being tested for the treatment of alcoholism and Double-blinding. ‘‘Blinding’’ of both the pa- alcohol abuse. These include the following: alcohol- tients and the physicians is necessary because of sensitizing agents; agents that directly attenuate their expectations and beliefs. Patients usually seek drinking behavior; agents to improve cognition in treatment in the expectation that the physician will patients with alcohol-induced impairments; and prescribe or recommend something that will cure or agents to treat psychiatric problems concurrent improve their condition. Hence, patients who re- with alcoholism. The most promising medications ceive placebos often feel better. Therefore, if a within each of the above categories are examined, placebo control is not used, one might conclude addressing their stage of development, clinical effi- that a new treatment works when one is only ob- cacy, potential side effects, and future research. serving the placebo kind of response. (Conversely, TREATMENT: Alcohol, Pharmacotherapy 1151 patients often report side effects when they take Multi-Site Trial. During the past decade, placebos. So not all side effects are necessarily due more rigorously designed clinical trials of di- to an active medication.) Physicians often believe sulfiram have been done, and these give more pre- very strongly that the newdrug willbe the effective cise information about the efficacy of disulfiram. treatment they are searching for, and their objec- The largest of these was a multi-site clinical trial tivity is diminished by this bias. To remove this done in nine Veterans Administration clinics (Ful- influence on their perception of the outcome of ler et al., 1986). In this study, 605 men were ran- treatment, the physicians treating the patients are domly assigned to three groups: ‘‘blinded’’ as well as the patients, hence a double- 1) a 250-milligram disulfiram group (the usual blinding is effected. dose); Accurate Assessment. If the methods used to 2) a 1-milligram disulfiram group; and assess the response to treatment do not accurately 3) a no-disulfiram group. measure the response to the medication, erroneous conclusions may be drawn (Fuller, Lee, & Gordis, The 1-milligram group was equivalent to a 1988). Patients’ self-reports about their response to placebo, because this dose is not sufficient to cause treatment should not be used without corrobo- a disulfiram—ethanol reaction (DER) but controls rating data in controlled clinical trials unless no for the expectation that one will get sick if one other means for obtaining information is available. drinks alcohol while taking disulfiram. The Such reports may be inaccurate for a variety of no-disulfiram group was told they were not receiv- reasons, including inaccurate memory and the ten- ing Antabuse; it was a control for the standard dency to give socially desirable answers. counseling that alcoholics receive in treatment. The It is also important to knowwhetherthe patients patients in the two disulfiram conditions were actually took the medications. Often, patients do ‘‘blinded’’ as to whether they were receiving the not take their medications or take them erratically, 250-milligram or the 1-milligram dose. The data to particularly if they are being treated for an asymp- judge the effect of treatment were collected by re- tomatic condition for a long period of time and/or if search personnel who had no involvement in the the medication has a high incidence of unaccept- treatment of the patients and were ‘‘blinded’’ to able side effects (Haynes, Taylor & Sackett, 1979). group assignment. The research staff members in- Patients who drop out of treatment frequently terviewed the patients, cohabiting relatives, and are atypical of all patients in treatment. In alcohol- friends (collaterals) every two months during the ism treatment, the dropouts are usually drinking year of follow-up. Urine specimens were collected and having problems because of their drinking. So, every time the patients returned to the clinic and if a study bases its conclusions only on those who were analyzed for the presence of alcohol. A vita- stay in treatment, the results of the therapy are min, riboflavin, was incorporated into the 250-mil- likely to be exaggerated. Therefore, it is important ligram and 1-milligram tablets. The nodisulfiram to locate and assess treatment response in all or patients received a tablet identical in appearance to almost all who initially began treatment. For an the disulfiram tablets but containing only ribofla- excellent description of clinical trials, their methods vin. The urine specimens were also analyzed for and issues, see Byar et al. (1976). riboflavin. This allowed the investigators to tell If control groups were used, methods other than whether the patients were taking their medications randomization were used to assign patients to the regularly. disulfiram group or the control group. Hence, the In contrast to most of the previous studies, this groups were not comparable, and placebo groups tightly designed study did not find that more of the were rarely used. ‘‘Blinding’’ was not done. No at- patients who received disulfiram stayed sober for tempts were made in most of the studies to deter- the year than those who received the placebo or mine whether patients took the medication. The counseling only. Nor was disulfiram associated with alcoholic’s report on abstention from alcohol was better employment or social stability; however, in the only information obtained to judge whether about 50 percent of the men who relapsed, drink- disulfiram was effective. In some studies, only ing frequency was significantly less for those who about half the patients were available for fol- received disulfiram than for those who received ei- low-up. ther the placebo or no disulfiram. This subset of 1152 TREATMENT: Alcohol, Pharmacotherapy men who relapsed by drinking less frequently if be monitored closely. The effectiveness of the drug assigned to disulfiram were slightly older and had may be enhanced if the patient agrees to take it more social stability (as indicated by longer resi- under supervision. dence at their current address) than the other men who relapsed. These results indicate that disulfiram ALCOHOL-SENSITIZING AGENTS is not more effective than routine treatment for most male alcoholics—female alcoholics were not The most commonly used alcohol-sensitizing included in the study—but may have some benefit agent is disulfiram, which has been used in clinical for socially stable male alcoholics. practice since the 1950s to deter alcoholics from In the multi-site study, only 20 percent of the drinking. It is not an aversive drug in the strict patients took the medication regularly; however, sense of the word, since it is not used, as apomor- abstinence for the year was highly associated with phine is used, to condition individuals to have an compliance with the disulfiram regimen. This sug- aversive response at the sight or smell of alcohol. gests that if ways were found to get patients to take Rather, its objective is to deter drinking by the disulfiram regularly, the effectiveness of the drug threat of having a very unpleasant reaction if one would be greatly improved. This conclusion has to does drink alcoholic beverages. Its severity depends be tempered by the finding that those who regularly on the amount of alcohol and disulfiram in the took the 1-milligram placebo or the vitamin with- blood. The symptoms of the reaction include facial out disulfiram, as well as those who took di- flushing, tachycardia (rapid heart beat), palpita- sulfiram, were much more likely to remain sober tions, dyspnea (indigestion), hypotension (lowered than those who were less adherent to their regi- blood pressure), headaches, nausea, and vomiting. mens. Nevertheless, alcoholism treatment research- Deaths have occurred with severe disulfiram— ers have studied various methods for improving ethanol reactions (DERs). compliance with disulfiram, and preliminary re- A DER results when alcohol is ingested because sults suggest that these may be beneficial. These disulfiram inhibits the functioning of an enzyme, treatment strategies have included having the aldehyde dehydrogenase. This enzyme is needed to spouse or a treatment facility staff member observe convert the acetaldehyde—the first metabolic the patient ingesting the medication, establishing a product in the catabolism of ethanol—to acetic contract with the patient about taking it, and/or acid. If aldehyde dehydrogenase is inhibited, an building in positive (rewards) or negative (loss of elevation in blood acetaldehyde results. The in- privileges) incentives to take it. A recent controlled creased circulating acetaldehyde is believed to study of disulfiram taken in the presence of a rela- cause most of the symptoms and signs of the DER. tive, friend, or member of the clinic staff found that Disulfiram is given orally. The usual dose is 250 this method of administration resulted in signifi- milligrams, although larger doses have been used. cantly less alcohol being consumed during a six- Doses of less than 250 milligrams may fail to cause month period (Chick et al., 1992). More well-de- a DER, while doses of more than 250 milligrams signed studies of these measures to improve com- have a greater risk of producing serious side effects. pliance with the disulfiram regimen are needed Adverse effects of disulfiram range from mild before it is known if they will improve the effective- symptoms such as sedation, lethargy, and a garlic- ness of disulfiram as a treatment for alcohol depen- like or metallic taste in the mouth to more serious dence. side effects such as major depression, psychotic On the basis of the large well-designed studies reaction, or idiosyncratic toxic hepatitis—which done to date, it seems prudent to recommend that may be fatal. A dose between 250 milligrams and disulfiram should not be used initially in the treat- 500 milligrams is usually adequate to cause a DER ment for alcoholism. However, if the patient re- if alcohol is ingested but not so high as to cause lapses and has indicators of social stability, a dis- major side effects. The dose should be individual- cussion with the patient about the possible benefits ized for each patient. and the possible risks of disulfiram is warranted, Alcohol-sensitizing agents other than disulfiram and if the patient is willing to take disulfiram, a also exist. CALCIUM CARBIMIDE, which is available in trial course is warranted. During the first six Canada under the brand name Temposil, has been months of treatment, it is important that liver tests used clinically, although it is currently not ap- TREATMENT: Alcohol, Pharmacotherapy 1153 proved by the FDA for use in the United States. alcoholics who were abstinent for four weeks than Calcium carbimide produces physiological reac- in nonalcoholics. Also, the availability of the sero- tions with alcohol similar to those produced by tonin precursor, tryptophan, appears to be lower in disulfiram, but the onset of action is quick—within alcoholics, particularly those in early onset of alco- one hour after administration—compared to holism (drinking before twenty years of age). twelve with disulfiram. Also, the duration of action SEROTONIN-UPTAKE INHIBITORS, commonly used is short—approximately twenty-four hours— to treat depression, seemed to be effective in reduc- versus up to six days with disulfiram. Calcium ing alcohol consumption in both animal models carbimide, with its faster onset of action, might be and humans. Serotonin-uptake inhibitors act by especially helpful with impulsive drinkers. A possi- preventing the uptake of serotonin during synaptic ble side effect of calcium carbimide is reduced transmission, resulting in a prolonged action. They thyroid function, however, thus making its use are easily administered (orally) and require only a problematic in patients with thyroid problems. It single daily dose. has some additional side effects that include dizzi- The serotonin-uptake inhibitors available for ness, slight depression, skin rashes, and impotence. clinical testing include fluoxetine (Prozac), One puzzling side effect of calcium carbimide is a fluvoxamine, citalopram, and viqualine. Several mild elevation in the patient’s white blood cell double-blind, placebo-controlled studies of these count. As of 2000, there is a paucity of randomized agents in various types of subjects—ranging from clinical trials comparing calcium carbamide to social drinkers to chronic alcoholics— showed an placebo—so, its efficacy is uncertain. increase in the number of abstinent days and a decrease in the number of drinks on drinking days AGENTS THAT ATTENUATE (Gorelick, 1989). The effect of the serotonin-up- DRINKING BEHAVIOR take inhibitors studied has, however, been modest (a 25% decrease in alcohol intake). The development of medications to curb drink- The precise mechanism of action of the seroto- ing behavior is one of the important and exciting nin-uptake inhibitors on drinking behavior is un- areas of alcohol research. In developing such medi- known. One of the most plausible explanations of- cations, researchers have relied on newinformation fered is their ability to suppress appetitive about the biological bases of drinking behavior and behaviors in general. However, consummatory be- alcohol craving. This process is complex and in- haviors are quite complex, and even this hypothesis volves the interactions among several neurochemi- may be an oversimplification. cal mechanisms, including NEUROTRANSMITTERS, In addition to the serotonin-uptake inhibitors, hormones, neuropeptides, RECEPTORS, second mes- agents that selectively block (antagonists) or acti- senger systems, and various ion channels in multi- vate (agonists) the subtypes of serotonin receptors ple regions of the brain. were considered promising. At least four major Recent research has focused on medications that types of serotonin (5-hydroxytryptamine, or 5-HT) alter the functional activity of several neurotrans- receptors exist: 5-HT1, 5-HT2, 5-HT3, and 5-HT4. mitter systems. In this section, we discuss medica- In turn, 5-HT1 has several subdivisions, including tions that directly attenuate drinking by acting on 5-HT1A receptor. Research in the early 1990s ap- the following neurotransmitter systems: SEROTO- peared to indicate that a 5-HT3 antagonist, on- NIN,OPIOIDS,DOPAMINE,andGAMMA-AMI- dansetron, reduced alcohol consumption in alcohol

NOBUTYRIC ACID (GABA). abusers (Toneatto et al., 1991). Also, 5-HT1A and Agents That Affect the Serotonin System. 5-HT2 receptors were believed to influence alcohol Several lines on animal and human research sug- intake. For example, buspirone, a 5-HT1A agonist gest that brain serotonin is associated with alcohol- and an antianxiety agent, was shown in some stud- ism. Serotonin levels are lower in several regions of ies to reduce alcohol consumption in humans. the brain in rats selectively bred to drink alcohol Finally serotonergic agents (e.g., fenfluramine) than in rats that do not prefer alcohol. In humans, that cause a release of serotonin from presynaptic measurements of cerebral spinal fluid levels of neurons were tested for clinical efficacy in reducing 5-hydroxyindoleacetic acid (5-HIAA), a metabolite alcohol intake. In addition, the administration of of serotonin, revealed lower levels of 5-HIAA in serotonin precursors was thought to alter drinking 1154 TREATMENT: Alcohol, Pharmacotherapy behavior. Several animal studies showed that tryp- in several studies, which have shown that blocking tophan (precursor to serotonin) and 5-hy- the serotonin 5-HT3 receptor with the antagonist droxtryptophan (hydroxylated form of tryptophan) ICS 205–930 results in an attenuation of alcohol- reduce the amount of alcohol consumed. induced release of dopamine in the nucleus accum- As of 2000, however, serotonergic agents have bens and corpus striatum of the rat brain (Wozniak not fulfilled their initial promise. A 1999 reviewof et al., 1990; Yoshimoto et al., 1991). forty-one major clinical studies of anti-alcohol Agents That Affect the Opioid System. medications and eleven follow-up studies reported Studies have shown that the opioid system also that the data from studies of serotonergic agents plays a role in modifying drinking behavior. Many were confounded by the high rates of comorbid researchers believe that alcohol craving and in- mood disorders in the subject populations. These creased drinking behavior are related to lowbrain medications appear to be useful primarily in the levels of endogenous opioids (compounds with treatment of alcoholics with concurrent psychiatric opium or morphine-like properties, e.g., diagnoses. ENDORPHINS and ENKEPHALINS). Subsequently, in- Agents That Affect the Dopamine System. creasing the opioid levels causes a decrease in DOPAMINE is another neurotransmitter identified drinking. This is supported by several studies. For as influencing drinking behavior. Dopamine is example, administration of the opioid agonist thought to play a major role in the stimulant and [D-Ala2,MePhe4,Met(O)5-ol]-enkephalin de- reinforcing properties of alcohol as well as other creases alcohol consumption in alcohol-preferring drugs. Decreased levels of dopamine are observed mice. Large doses of morphine (a classic opioid UCLEUS ACCUMBENS of alcohol-seeking rats in the N agonist) also result in a significant reduction in (as compared with nonalcohol-seeking rats). The alcohol intake. In addition, increasing the avail- nucleus accumbens is the region of the brain be- ability of endogenous enkephalins by injecting mice lieved to be involved with alcohol craving. Studies with the enkephalinase inhibitor kelatorphan in the early 1990s demonstrated that the applica- (which prevents breakdown of endogenous en- tion of alcohol to the nucleus accumbens and stria- kephalins) results in decreased alcohol consump- tum of a rat brain causes a release of dopamine tion. Finally, one study demonstrated that high- (Wozniak et al., 1991; Yoshimoto et al., 1991). risk individuals (those who have a family history of The administration of medications that increase alcoholism) have lower plasma levels of beta- brain dopamine levels (bromocriptine, GBR 12909, and amphetamine) results in a reduction of endorphin than do low-risk individuals (no family alcohol intake in alcohol-preferring rats. Several history of alcoholism for at least the three preced- studies have been conducted in humans using the ing generations). Some researchers have challenged the hypothe- dopamine type 2 agonist (D2) bromocriptine. One study (Borg, 1983) indicated that bromocriptine sis that excessive drinking is related to decreases in reduced alcohol craving and consumption in severe endogenous opioid levels. Experimental evidence alcoholics, while another (Dongier et al., 1991) includes the observation that lowdoses of mor- found a reduction in alcohol consumption and an phine cause an increase in alcohol intake in rats. improvement in psychological problems in both Regardless of the mechanism of action, the opi- bromocriptine-treated and placebo alcoholics, al- oid ANTAGONISTS NALTREXONE and NALOXONE— though no significant differences were observed be- currently used to treat opiate abuse—have been tween the two groups. shown to influence alcohol consumption. Both The efficacy of the dopaminergic medications in agents reduce voluntary alcohol intake in rats and the long-term management of alcoholism is cur- monkeys. In humans, studies have shown that alco- rently unclear. Further research needs to be con- holics treated with naltrexone have fewer drinking ducted on the two major subtypes of dopamine days, fewer relapses, and less subjective craving for receptors, D1 and D2. In addition, their interaction alcohol (Volpicelli et al., 1992; O’Malley et al., with other neurotransmitter systems needs to be 1992). In addition, naltrexone (Trexan) appears to investigated. An illustration that neurotransmitter cause fewside effects. Interestingly, naltrexone- systems do not work in isolation and that a medica- treated alcoholics who did have one or two drinks tion affecting one may also alter another is present were less likely to continue drinking. This is impor- TREATMENT: Alcohol, Pharmacotherapy 1155 tant, since some alcoholics appear to lose control of AGENTS TO IMPROVE drinking after one or two drinks. COGNITIVE FUNCTION Naltrexone was the subject of a number of clini- Chronic heavy drinking can lead to impairment cal trials in the United States; as of August 2000, of most cognitive functions, including abstract ten out of thirty NIH-sponsored clinical trials were thinking, problem solving, concept shifting, psy- studies of naltrexone. However, a review of phar- chomotor performance, and memory. The two most macotherapeutic agents presented to the National common diseases of cognitive impairment in alco- Institute on Alcohol and Alcohol Abuse (NIAAA) in holism are alcoholic amnestic disorder (WERNICKE- November 1999 concluded that the effectiveness of Korsakoff syndrome) and alcoholic dementia. Al- naltrexone in the treatment of alcoholism appears coholic amnestic disorder is associated with pro- to be limited. Another reviewof pharmacotherapy longed and heavy use of alcohol and is character- in the treatment of alcoholism published in the ized by severe memory problems. Though the exact Journal of the American Medical Association cause is unknown, this disease is thought to be (1999) noted that naltrexone reduces the relapse preventable by proper diet, including vitamins, particularly the B vitamin thiamine. The other im- rate and the frequency of drinking in alcoholics, pairment, alcoholic dementia, has a gradual onset but does not substantially enhance the abstinence and thus displays various degrees of cognitive im- rate. Studies of a similar compound, nalmefene, pairment, including difficulties in short-term and yielded the same results. long-term memory, abstract thinking, intellectual A secondary drawback to the use of naltrexone abilities, judgment, and other higher cortical func- in treating alcoholism is the apparent reluctance of tions. many physicians to prescribe it. An NIH study of Most studies indicate that alcoholics with im- physicians in three representative states found that paired cognitive function will have poorer treat- very fewused it withtheir patients. The reasons ment outcome. This, of course, depends on the given were the physicians’ lack of familiarity with severity of impairment. Little research has been the drug, and its relatively high cost to the patients. conducted with medications to improve cognitive Agents That Affect the GABA System. function. Serotonin-uptake inhibitors have shown Several studies have nowinvestigated the GABA some promise in improving learning and memory. system as a modulator of drinking behavior. The One study with the serotonin-uptake inhibitor number of GABAergic receptors appears to be fluvoxamine demonstrated improvement in mem- greater in the nucleus accumbens region of the ory in patients suffering from alcohol amnestic disorder, but not in patients with alcoholic dementia. brain of alcohol-preferring rats than in those of the alcohol-nonpreferring rats. An anti-craving drug that is presently approved for use in the European AGENTS TO TREAT PSYCHIATRIC DISORDERS CONCOMITANT Community, acamprosate (calcium acetyl- TO ALCOHOLISM homotaurinate), is thought to inhibit presynaptic GABA (B) receptors in the nucleus accumbens Alcoholism may be accompanied with various (Berton et al., 1998). A German researcher has psychiatric problems including anxiety, depression, noted that this newanti-craving medication has no antisocial behavior, panic disorders, and phobias. psychotropic side effects nor any potential for Part of the problem in treatment is to determine if abuse or dependence. Acamprosate lacks hypnotic, the psychiatric disorder developed before alcoholism (primary), or after (as a result of) alcoholism anxiolytic, antidepressant, and muscle-relaxant (secondary). Nevertheless, several studies have properties (Zieglgaensberger, 1998). Although been conducted predominately with medications acamprosate is being used in clinical trials in the used to treat depression and anxiety. United States as of 2000, however, its effects are Agents to Treat Alcoholics with Depression. unclear. It appears to reduce the frequency of Depression has been associated with alcoholism, drinking, but its effects on enhancing abstinence especially with relapse to drinking. A frequent are no greater than those of naltrexone. pharmacologic treatment of depression is with a 1156 TREATMENT: Alcohol, Pharmacotherapy

group of medications called tricyclic ANTIDEPRES- An attractive feature of buspirone is that its use SANTS (desipramine, imipramine, amitriptyline, does not lead to physical dependence on the drug, and doxepin). Their efficacy in treating alcoholics as with antianxiety drugs, particularly with with depression is, however, largely unknown. This BENZODIAZEPINES. Furthermore, buspirone lacks is in part because of poor methodological studies. A side effects often found with anxiolytic medica- recent study of desipramine was conducted on alco- tions. For example, buspirone lacks sedative, anti- holics with and without secondary depression (Ma- convulsant, and muscle-relaxant properties, does son & Kocsis, 1991). Preliminary findings showed not impair psychomotor, cognitive, or driving that desipramine is effective in reducing depression skills, and does not potentiate the depressant ef- in the depressed group and may also prolong the fects of alcohol. period of abstinence from alcohol in both depressed Administration of buspirone to rats and mon- and nondepressed patients. Preliminary results of keys has resulted in a decrease in alcohol intake another study suggested that imipramine both im- (Litten & Allen, 1991). In humans, one study re- proves mood and reduces drinking in alcoholics ported that buspirone diminished alcohol craving suffering from major (primary) depression. and reduced anxiety. Another study found In addition to the tricyclic antidepressants, the buspirone to be more effective with alcoholics suf- serotonin-uptake inhibitors are used to treat de- fering from high anxiety than those with low levels pression. One of these inhibitors, fluoxetine (Pro- of anxiety. A third study on more severe alcoholic zac), is widely used as an antidepressant. As dis- patients found no effect. Thus, further research is cussed earlier, fluoxetine has been studied to see needed before this drug’s efficacy can be accurately whether it attenuates drinking behavior in nonde- evaluated. pressed alcoholics, but findings as of 1999 indicate that its usefulness is limited to alcoholics in the In summary, the evidence indicates that effec- dual-diagnosis population. tive treatment of a psychiatric disease may also be Lithium, an effective medication for the treat- beneficial to the treatment of alcoholism, particu- ment of manic-depressive disease, has also been larly in alcoholics with coexisting psychiatric disor- studied as a pharmacologic agent in the treatment ders, but that psychoactive medications are not of alcoholic patients. In one multi-site clinical study ‘‘magic bullets’’ for most alcoholics. of lithium in depressed and nondepressed alcoholics, lithium therapy was not effective in reducing CONCLUSIONS the number of drinking days, improving abstinence, decreasing the number of alcohol-related Development of newmedications to decrease hospitalizations, or reducing alcoholism depen- drinking, prevent relapse, and restore cognition dence (Dorus et al., 1989). This investigation as may have a role in alcoholism treatment in the well as other studies did not address the effective- future—but as a part of treatment regimens— ness of lithium in other types of psychiatric disor- given with other nonpharmacological therapies. ders that may respond—including hypomania (a Advances in understanding the mechanisms re- mild degree of mania), bipolar manic-depressive sponsible for alcohol craving, drinking behavior, illness, and other mood disorders. Studies of lith- cognition, and even some of the psychiatric disor- ium in the 1990s concluded that it lacks efficacy in ders such as depression and anxiety disorders have the treatment of alcoholism. not yet produced a medication that substantially Agents to Treat Alcoholics with Anxiety Dis- improves abstinence rates. Some researchers have orders. Recent studies have indicated that a size- recommended a careful matching of subgroups of able proportion of individuals who abuse alcohol alcoholics to the medications that are presently also suffer from anxiety disorders. Buspirone, an available as a possible pharmacological treatment agent commonly used to treat anxiety, has shown strategy. potential in reducing alcohol consumption. As dis- Moreover, as of 2000, there is much that is still cussed earlier, buspirone acts as an agonist on the not known about the pharmacological treatment of serotonin 5-HT1A receptors and also alters the do- alcoholism. The 1999 NIAAA report outlined three pamine and norepinephrine systems. major areas of inquiry that need further research: TREATMENT: Cocaine, An Overview 1157

The optimal dosing strategy for anti-alcohol MASON, B. J., & KOCSIS, J. H. (1991). Desipramine treat- medications and the optimal duration of ment of alcoholism. Psychopharmacology Bulletin, treatment. 27, 155–161. The possible utility of combination therapies, NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM either combinations of different medica- (NIAAA). (1999). NIAAA Council Review of the Ex- tions or combinations of medication and tramural Portfolio for the Treatment of Alcoholism. psychotherapy. Bethesda, MD: Author. The usefulness of speciﬁc pharmacotherapies O’MALLEY, S. S., ET AL. (1992). Naltrexone and coping for women; different ethnic and racial skills therapy for alcohol dependence. Archives of groups; adolescent and geriatric patients; General Psychiatry, 49, 881–887.

and polydrug abusers. TONEATTO, T., ET AL. (1991). Ondansetron, a 5-HT3 antagonist, reduces alcohol consumption in alcohol (SEE ALSO: Complications; Disease Concept of Al- abusers. Alcoholism: Clinical and Experimental Re- coholism and Drug Abuse; Drug Interactions and search, 15, 382. Alcohol; Drug Metabolism; Treatment, History of ) VOLPICELLI, J. R., ET AL. (1992). Naltrexone in the treatment of alcohol dependence. Archives of General Psy- BIBLIOGRAPHY chiatry, 49, 876–880. WOZNIAK, K. M., PERT, A., & LINNOILA, M. (1990). An- BERTON, F., ET AL. (1998). Acamprosate enhances tagonism of 5-HT3 receptors attenuates the effects of N-methyl-D-apartate receptor-mediated neurotrans- ethanol on extracellular dopamine. European Journal mission but inhibits presynaptic GABA (B) receptors of Pharmacology, 187, 287–289. in nucleus accumbens neurons. Alcohol in Clinical WOZNIAK, K. M., ET AL. (1991). Focal application of and Experimental Research, 22, 183–191. alcohols elevates extracellular dopamine in rat brain: BORG, V. (1983). Bromocriptine in the prevention of A microdialysis study. Brain Research, 540, 31–40. alcohol abuse. Acta Psychiatrica Scandinavica, 68, YOSHIMOTO, K., MCBRIDE, W. J., LUMENG, L., & LI, T.-K. 100–110. (1991). Alcohol stimulates the release of dopamine CHICK, J., ET AL. (1992). Disulfiram treatment of alcohol- and serotonin in the nucleus accumbens. Alcohol, 9, ism. British Journal of Psychiatry, 161, 84–89. 17–22. DONGIER, M., VACHON, L., & SCHWARTZ, G. (1991). Bro- ZIEGLGAENSBERGER, W. (1998). Acamprosate, a novel mocriptine in the treatment of alcohol dependence. anti-craving compound, acts via glutaminergic path- Alcoholism: Clinical and Experimental Research, 15, ways. Paper presented at the National Institute on 970–977. Drug Addiction (NIDA) conference on glutaminergic DORUS ET AL , W., . (1989). Lithium treatment of de- agents, May 1998. Bethesda, MD: National Institutes pressed and nondepressed alcoholics. Journal of the of Health. American Medical Association, 262, 1646–1652. RICHARD K. FULLER FULLER, R. K., LEE, K. K., & GORDIS, E. (1988). Validity of self-report in alcoholism research: Results of a Vet- RAYE Z. LITTEN erans Administration cooperative study. Alcoholism: REVISED BY REBECCA J. FREY Clinical and Experimental Research, 12, 201–205. FULLER, R. K., ET AL. (1986). Disulfiram treatment of alcoholism: A Veterans Administration cooperative Cocaine, An Overview COCAINE abuse and study. Journal of the American Medical Association, dependence should be approached as chronic disor- 256, 1449–1455. ders that require long-term treatment. The clinical GARBUTT, J. C., ET AL. (1999). Pharmacological treat- course of cocaine addiction is often progressive and ment of alcohol dependence: A reviewof the evidence. generally marked by recidivism. Addiction to co- Journal of the American Medical Association, 281, caine should be approached as a brain disease, and 1318–1325. not a weakness to be viewed with judgmental over- GORELICK, D. A. (1989). Serotonin uptake blockers and tones. In fact, cocaine produces a number of neuro- the treatment of alcoholism. In Recent Developments chemical alterations in the brain, especially in the in Alcoholism: Treatment Research, Vol. 7. NewYork: reward centers of the midbrain and in the limbic Plenum Press. system. When evaluating a patient for treatment, 1158 TREATMENT: Cocaine, An Overview many factors must be taken into consideration. other segments of our population. Many users tend First, patients presenting for treatment often have to administer cocaine several times per week in complicating factors, such as coexisting psychiatric intense bursts, or binges. A binge may last several disorders, family problems, job jeopardy, and med- hours or even several days. In these individuals the ical complications. These problems are often why binge is usually terminated by exhaustion of sup- the person is seeking treatment, and should be fully plies or by behavioral, cardiovascular, or neurolog- explored and linked to the addiction. Interpersonal ical side effects. Binges are often perpetuated by the and occupational dysfunction often results from phenomenon of cocaine use producing additional cocaine becoming the addict’s number one priority, cocaine CRAVING. It is not typical to see individuals taking precedence over family and financial re- able to maintain lowor moderate doses of cocaine sponsibilities. Medical problems frequently result when used on a daily basis. from cocaine’s destructive action on the heart, The higher the dose of cocaine reaching the ner- brain, and kidneys, while co-occurring psychiatric vous system and the longer the period of use, the disorders commonly include paranoia, depression, more likely that there will be some form of behav- and anxiety. To a great extent, the presence of these ioral toxicity. Personality change consisting of irri- disorders depends on the length of time the individ- tability, suspiciousness, and paranoia may occur. ual has been using cocaine, the dose of cocaine Psychosis with HALLUCINATIONS and persecutory taken, and the route of administration. As individ- delusions, often associated with the likelihood of uals progressively lose control over cocaine intake, violence, is also seen in heavy cocaine users. Audi- they become more likely to experience interper- tory hallucinations are the most common, but sonal, medical and psychiatric complications. tactile and gustatory hallucinations are occasionally reported. During the crash period after termi- COCAINE USE PATTERNS nation of a binge of cocaine use, there is often DE- PRESSION. The period of depression is usually brief, Cocaine may be taken in various ways that differ but in some patients it can trigger a major affective in speed of onset, in blood levels, and, conse- disorder, which is a psychiatric syndrome requiring quently, in brain levels. Subjective effects are most ANTIDEPRESSANT medication. Cocaine addicts of- intense when brain levels of cocaine are rapidly ten report suicidal thoughts, especially during the increasing to high concentrations. Routes of admin- crash period. For most patients, cocaine WITH- istration, in ascending order of efficiency, are chew- DRAWAL consists of several days of gradually de- ing COCA leaves (absorption through the mucous creasing depression and fatigue with episodes of membranes of the mouth), oral ingestion of cocaine craving for cocaine. hydrochloride, intranasal absorption of cocaine hydrochloride, smoking of alkaloidal (FREEBASE) co- PHASES OF TREATMENT caine (CRACK), and intravenous injection of cocaine hydrochloride. The use of crack is actually Treatment can be divided into three phases: the most rapid delivery of cocaine to the brain, and (1) achievement of initial abstinence or detoxifica- generally preferred over intravenous use. tion; (2) rehabilitation; and (3) aftercare. The There are also different use patterns. Some pa- treatment of cocaine abuse or dependence should tients rarely use cocaine except at parties and in always be thought of in terms of these phases, and relatively lowdoses. Some ethnic and social groups the patient and the patient’s family should be told are particularly likely to use cocaine by the intra- to anticipate a period of treatment lasting at least nasal route, a method that achieves lower brain eighteen months and often three years or longer. levels than administration via crack (freebase inha- Achievement of Initial Abstinence. Initial lation) or the intravenous route. Women and ado- abstinence can be difficult to achieve if severe with- lescent users are more likely to use crack, which is drawal symptoms are present, although most pa- inexpensive per unit dose. A vial of crack sufficient tients do not experience the cocaine ‘‘crash’’ be- to produce a brief, intense period of euphoria aver- cause they use irregularly, stopping and restarting ages two to three dollars in some large East Coast cocaine frequently. Although there is a definite co- cities. Affordability essentially increases the access caine withdrawal syndrome, it has an irregular pat- of this highly addictive drug to our youth, and to all tern and does not fit neatly into distinct phases. TREATMENT: Cocaine, An Overview 1159

Careful studies of patients going through cocaine pulsive cocaine use. Some clinicians recommend withdrawal reveal an early severe period of inpatient treatment to establish abstinence and be- dysphoria, depression, fatigue, and sleepiness. gin rehabilitation in severely addicted patients. In- Over the ensuing hours and days gradual improve- patient treatment by itself is never sufficient and ment occurs. There may also be physical signs, must be followed by an outpatient phase of rehabil- such as a bradycardia (slowheart rate) that gradu- itative treatment during which time the patient has ally returns to normal. These withdrawal symp- returned to his or her prior living environment. toms may be accompanied by periodic severe Outpatient treatment may be especially difficult if craving for cocaine. If a patient is being treated on the patient lives in a drug environment and is an outpatient basis, achieving abstinence can be subject to daily cues that trigger cocaine craving. very difficult. Many clinicians recommend giving all patients an To assist in the achievement of initial absti- initial trial of outpatient treatment, reserving in- nence, researchers have attempted to identify med- patient treatment only for those who repeatedly fail ications that might help reverse brain alterations in less expensive outpatient programs. This ap- known to result from chronic cocaine exposure. proach is generally embraced by managed care DOPAMINE, a neurotransmitter involved in natural organizations. In many areas of the country, access reward, appears to mediate the ‘‘high’’ associated to inpatient treatment is only available for cocaine with cocaine. There is substantial evidence that addicts with serious medical or psychiatric condi- repeated cocaine use depletes brain dopamine, tions. leading clinical investigators to test dopamine Although the effectiveness of inpatient versus agents in cocaine patients. Bromocriptine stimu- outpatient treatment is pertinent to millions of lates dopamine receptors but is associated with side afflicted individuals, there has been surprisingly effects, and has not been proven effective in pre- little actual research in this area. One study made a venting RELAPSE. Fewclinicians currently recom- direct comparison between outpatient and in- mend its use to treat acute cocaine withdrawal. patient rehabilitation. Patients at the Philadelphia Another dopaminergic medication, AMANTADINE, Veterans Administration Medical Center were ran- has been researched in an outpatient study to help domly assigned to either an 18-day inpatient reha- patients achieve initial abstinence. It is very impor- bilitation treatment or outpatient rehabilitation tant to evaluate potential medications for any dis- that included a hospital day program. The hospital order by using a comparison or control group. Typ- day program was similar to the inpatient rehabili- ically a group of patients is randomly assigned to tation program and based on the TWELVE STEPS receive either the drug to be tested or a placebo. with emphasis on group therapy and peer support. Patients are given identical-appearing capsules so Some individual therapy was provided for both that neither the patients nor the physicians know groups. Patients came to the day hospital five days who is receiving the test drug and who is getting the per week for more than five hours of therapy per placebo. Such a double-blind trial determined a day, and returned home in the evening. Those in significant advantage for patients randomly as- the inpatient program remained in treatment seven signed to amantadine as compared with the group days per week, twenty-four hours per day. At the receiving a placebo. This advantage was found only end of the twenty-eight-day program, both groups during the initial two-week phase of treatment, were encouraged to continue treatment in an after- when the goal is achievement of abstinence, and care program consisting of weekly visits to the out- further research is underway at present to evaluate patient clinic. At the end of four months and at the this dopamine agent. Another outpatient study end of seven months, evaluations were conducted found desipramine to be helpful in achieving early on all patients initialing the study, even if they had abstinence and maintaining it for six weeks. This dropped out immediately after beginning. The re- was relatively early in the cocaine epidemic, and sults showed that there were fewer dropouts in the the patients were all intranasal users. More severely inpatient program, but there was no significant cocaine-dependent patients have generally failed to difference between the two groups. Both had a 50 respond this well to desipramine. to 60 percent success rate at the two follow-up Rehabilitation Phase. The major emphasis of periods. Success was defined as no cocaine use for treatment should be prevention of relapse to com- the prior thirty days, supported by a negative urine 1160 TREATMENT: Cocaine, An Overview test at the time of the interview. This study has showany benefit for this anticonvulsant medication been cited as supporting the use of less expensive in prevention of relapse. Bromocriptine was not outpatient treatments for cocaine addicts. found to improve recovery rates when used in a Although some individuals are able to stop co- relatively high dose, perhaps due to study dropouts caine use and remain permanently abstinent, most motivated by excessive side effects. There have experience slips to cocaine or other drugs. A slip been claims of benefit for acupuncture, but there is does not necessarily denote relapse or treatment no scientific evidence to support is efficacy in co- failure, provided the patient is willing to resume caine dependence. There have also been unsub- counseling and is interested in preventing subse- stantiated reports in the lay literature that the hal- quent use. Slips often occur when patients deviate lucinogenic drug IBOGAINE produces a long-term from treatment recommendations, and treatment loss of craving for cocaine. The lay press has re- compliance can be reestablished in their aftermath. ported three deaths from the use of this drug and However, slips may turn into ‘‘runs’’ of heavier and animal studies report neuronal toxicity after heavier cocaine use, resulting in a decision to drop ibogaine administration. Baclofen, a drug that indi- out of treatment and return to active addiction. rectly affects dopamine neurons through GABA This is the danger of a slip, and the basis of recom- systems in the brain, may be effective against co- mending total abstinence. The use of other addic- caine craving for theoretical reasons, and is cur- tive agents, such as OPIATES,ALCOHOL,SEDATIVES rently under investigation. and MARIJUANA, should also constitute a slip. Al- Psychotherapy during Rehabilitation. In though clinicians have recognized the need for ab- addition to standard treatments provided in most stinence from all addictive substances when treat- rehabilitation programs, such as the twelve-step ing cocaine patients, it has only recently been program, group and family therapy, there have demonstrated in a research study that the use of been studies using specific manual-driven psycho- alcohol leads to significantly lower recovery rates. therapy and behavioral therapy. A recent report of Based on knowledge of the pharmacological ef- a large-scale multi-center study demonstrated su- fects of cocaine, there has been an intensive search perior results with individual drug counseling. Fur- for medications that serve as effective adjuncts in thermore, the effectiveness of individual drug the rehabilitative phase. Cocaine is known to block counseling correlated highly with attendance in the dopamine transporter, a specialized membrane twelve-step group meetings. protein that clears cocaine from the synaptic space Reinforcement of Clean Urine. Another after it has been released, thus helping to terminate treatment approach that has resulted in significant neurotransmission. Cocaine use consequently pro- success is using systematic reinforcement of cocaine duces excessive dopaminergic stimulation, contrib- abstinence. Researchers arranged for patients to be uting to the pleasurable effects of the drug. Cocaine rewarded with vouchers that could be exchanged also increases the availability of other neurotrans- for desirable goods, restaurant meals or other con- mitters, such as serotonin, norepinephrine, and structive purchases when they presented drug-free glutamate. The search for a medication to improve urine. This treatment approach was accepted well the results of cocaine treatment has focused largely by patients, and the results were significantly better on substances that influence dopamine mecha- than those for a control group receiving counseling nisms, either presynaptic or at the receptor level, alone. A one-year follow-up of patients previously and medications that influence brain systems uti- treated for six months in this manner showed that lizing GABA, glutamate, and serotonin. 71 percent were abstinent during the thirty days Unfortunately, the results of medication re- prior to the follow-up interview. search have been disappointing. Desipramine was A similar study has been conducted with opiate- initially reported to be of some benefit in this phase dependent patients who were using cocaine while of treatment, but subsequent studies involving se- enrolled in a methadone program. A program of vere cocaine dependence failed to replicate early reinforcement of clean urine using vouchers that reports of success. Carbamazepine was proposed as could be exchanged for desirable objects produced a treatment based on its ability to block the devel- a significant reduction in cocaine use. The use of opment of subcortical seizure activity produced by vouchers to improve retention in treatment, and cocaine. Controlled studies, however, have failed to enhance recovery rates, is the focus of a large gov- TREATMENT: Cocaine, An Overview 1161 ernment-sponsored effectiveness study currently that the patient needs to resume intensive treat- underway. ment for a chronically relapsing disorder. Most cli- Extinction of Cocaine-Related Cues. Even nicians agree that regular daily attendance in highly motivated former cocaine-dependent pa- twelve-step groups should supplement professional tients experience craving after the cessation of co- treatment, at least for the first 90 days of recovery. caine use. While they are in a protective hospital Thus far, there is no evidence that any medication environment, addicts often feel confident that they is helpful in this phase of treatment. Of course, if can remain abstinent. However, upon returning to the patient remains depressed or anxious, or has their previous neighborhoods they encounter envi- symptoms of another psychiatric disorder, specific ronmental cues that typically result in excitement treatment such as antidepressants should be em- and cocaine craving. These cues usually are people, ployed. places, and things that had previously been linked to cocaine use. Many patients say they become so SUMMARY conditioned to the effects of cocaine that simply seeing their drug dealer or a vial of cocaine pro- Cocaine abuse and dependence represent chron- duces a rush long before the drug gets into their ic disorders that require long-term treatment. A body. Cue craving has recently been shown to pro- brief initial inpatient phase may be necessary, but duce a discernible signature of brain activity with the major part of treatment consists of’ long-term the use of PET scanning. Treatments have been outpatient care. Since cocaine addiction is associ- designed to reduce or extinguish these conditioned ated with progressive deterioration in functioning, responses. They consist of repeatedly reviewing and can produce dangerous medical and psychiat- drug-related stimuli and learning various coping ric complications, aggressive treatment is war- skills, such as the relaxation response, visual imag- ranted. Various treatment techniques can be used. ery, and mastery techniques. These techniques are Most patients receive group therapy and counseling used by behavioral therapists to reduce the symp- based on the Twelve Steps developed by ALCOHOL- toms of other disorders, such as phobias or obses- ICS ANONYMOUS. Professional psychotherapy may sive-compulsive disorder. For cocaine dependence, be helpful in selected cases, but data are still pre- the patient can be taught the techniques by a thera- liminary. There are also data showing efficacy for pist. Later, the patient can practice the techniques behavioral treatments, such as contingent voucher in the clinic by viewing videos of cocaine use. There reinforcement of clean urine and extinction of cue is nowevidence that patients randomly assigned to craving produced by cocaine-related stimuli. Still, these behavioral treatments do significantly better recovery rates from cocaine dependence are disap- in outpatient treatment than control subjects as- pointingly low, and treatment approaches are being signed to standard treatment with the same amount refined. Cocaine use tends to occur in epidemics, of attention. especially when there is little perceived danger of it. Aftercare. After about a month of intense re- We appear to be experiencing a dramatic reduction habilitation treatment, a patient can graduate to an in cocaine use, perhaps because cocaine is widely aftercare program of variable intensity. Sessions perceived as dangerous. Therefore, the most effec- may initially be once or twice a week, decreasing tive means of treating cocaine dependence may ul- gradually to once or twice per month. Urine testing timately involve education of its risks directed should be continued to monitor drug use. The co- toward individuals not yet caught in its grasp. caine metabolite, benzoylecgonine, remains in the urine for several days and can effectively signal the BIBLIOGRAPHY resumption of cocaine use. Patients who admit to a slip or whose urine tests indicate cocaine use should ALTERMAN, A. I., ET AL. (1992). Amantidine may facili- resume intensive counseling. Every attempt should tate detoxification of cocaine addicts. Drug and Alco- be made to determine why the slip occurred so that hol Dependence, 31, 19–29. it can be avoided in the future. As previously dis- ALTERMAN, A. I., & MCLELLAN, A. T. (1993). Inpatient cussed, a slip of this nature should not necessarily vs. day hospital treatment services for cocaine and be considered indicative of treatment failure, even alcohol dependence. Journal of Substance Abuse if it results in a significant binge. It is instead a sign Treatment, 10, 269–275. 1162 TREATMENT: Cocaine, Behavioral Approaches

CRITS-CHRISTOPH,P.ET AL. (1999). Psychosocial treat- OUTPATIENT VERSUS ments for cocaine dependence. Archives of General INPATIENT TREATMENT Psychiatry, 56(6), 493–502. Studies suggest that inpatient rehabilitation is CHILDRESS,A.R.ET AL. (1999). Limbic activation dur- not cost-effective in most cases of cocaine depen- ing cue-induced cocaine craving. American Journal of dence. It is also not necessary in most cases because Psychiatry, 156(1), 11–18. withdrawal from cocaine addiction is not physically DACKIS,C.A.&GOLD, M. S. (1985). Newconcepts in dangerous, nor does it cause an incapacitating re- cocaine addiction: the dopamine depletion hypothe- action. However, inpatient treatment may be indi- sis. Neuroscience and Biobehavioral Reviews, 9(3), cated in some instances of cocaine dependence if 469–77. the patient (1) fails to make progress or deterio- HIGGINS, S. T., ET AL. (1991). A behavioral approach to rates during outpatient treatment; (2) has severe achieving initial cocaine abstinence. American Jour- medical or psychiatric problems; (3) is physically nal of Psychiatry, 148(9), 1218–1224. dependent on other drugs, or (4) has a history of MCKAY,J.R.ET A.. (1999). The relationship of alcohol criminal involvement. In general, learning to cope use to cocaine relapse in cocaine dependent patients in with the multitude of environmental circumstances an aftercare study. Journal of Studies on Alcohol, that have contributed to the initiation and mainte- 60(2), 176–80. nance of cocaine abuse is the most important task of the abuser. This task can be accomplished effec- CHARLES P. O’BRIEN tively only outside the hospital. REVISED BY CHARLES A. DACKIS Therapeutic communities, or residential programs with planned lengths of stay of six to twelve months, focus on the resocialization of the individ- Cocaine, Behavioral Approaches No ual to society. Resocialization programs at such consensus exists about howto treat C OCAINE de- communities may include vocational rehabilitation pendence. This statement is particularly alarming and other supportive services. One study has shown that improved cocaine relapse rates for patients given that in 1998 it was estimated that 1.8 million with medium- to high-level problems were depen- persons in the United States were dependent on dent on longer treatment stays. cocaine. The abuse of cocaine was first recognized in the medical literature in the late 1800s. Early COCAINE ANONYMOUS proposed treatments included various herbal and medical potions, nutritional supplements, hot COCAINE ANONYMOUS (CA) is a community- baths, substitution of MORPHINE, long stays in san- based self-help group organization modeled after atoriums, education, and psychotherapy. System- ALCOHOLICS ANONYMOUS (AA). The basic princi- atic evaluation of the effectiveness of these early ples are the same as AA’s. The program is based on treatments did not occur. the ‘‘disease’’ model of substance dependence. The goals and focus of behavioral approaches Achievement and maintenance of abstinence from for cocaine dependence vary greatly depending on cocaine is presumed to be facilitated by following the beliefs held by the treatment provider regarding the Twelve Steps of CA (which are based on the the causes of cocaine dependence. The efficacy of original TWELVE STEPS of AA). CA is available to anyone who expresses a desire the various treatments is only beginning to be eval- to stop using cocaine and all other mind-altering uated. This article describes the primary behavioral substances. All that is necessary to become a group approaches used to treat cocaine and discusses the member is that one attend meetings. Meetings vary efficacy of those interventions. Although numerous from large open ones that anyone can attend to behaviorally-based interventions are being used as small, closed discussions reserved for specific treatments for cocaine dependence, this article is groups. For example, a group of young people, limited to providing an overviewand discussion of professionals, or women is organized to address approaches that have received attention in the sci- specific concerns. At most meetings, experiences entific literature. are shared and advice and support are given. Two TREATMENT: Cocaine, Behavioral Approaches 1163 other components of the CA program are sponsor- significant differences in demographic, personality, ship and education. A sponsor is a person who has or addiction severity variables or in treatment re- been in recovery for a substantial period of time tention or 9-month outcome between cocaine abus- and who is available at any time to provide support ers who choose individual therapy and those who and guidance to the person attempting to recover. choose group therapy. Education about the ‘‘disease’’ is provided through pamphlets, books, films, and other literature. CA is SUPPORTIVE-EXPRESSIVE AND recommended by many treatment professionals as INTERPERSONAL PSYCHOTHERAPY the treatment for, or as an important adjunct of treatment for, persons with cocaine problems. Psychotherapy is usually suggested as a component of cocaine-treatment programs, both inpatient and outpatient. Typically, the therapy is based on GROUP THERAPY psychodynamic theories of substance abuse. This Many professionals suggest that group therapy is means that intrapersonal factors and underlying an invaluable component of cocaine abuse treat- personality disturbances are considered causes of ment. Most groups are structured to include per- cocaine abuse. It is presumed that cocaine is used to sons of different backgrounds and at different cope with painful emotional states, and that issues stages of recovery (1) to help deal with feelings of such as separation-individuation, depression, and uniqueness, (2) to expose those in the early stage of dependency must be resolved to maintain absti- treatment to positive role models, and (3) to help nence. The therapist tends to adopt an exploratory instill hope for success. Those who promote group role that promotes insight into interpersonal and therapy viewpeer pressure and support as neces- intrapersonal conflict underlying the cocaine de- sary to overcome ambivalence about abstaining pendence. Increased insight is presumed to result in from cocaine. Providing support for others and the a reduction in the underlying problems, which, in development of intimate social interaction (e.g., turn, should help promote cocaine abstinence. sharing of feelings) is facilitated and presumed to The psychotherapeutic approaches for cocaine be therapeutic. abusers are generally similar to the approaches for Topics of discussion in group therapy vary de- abusers of other drugs, although treatments for AL- pending on the group members and the orientation COHOLISM and drug abuse have evolved somewhat of the therapist. Topics may include early absti- differently and the models used may conflict at nence issues, guilt resolution, marital conflict, or certain points. A great deal of discussion has been lifestyle changes. Education about adverse effects generated about these conflicts in combined treat- of cocaine is often included. Group therapy occurs ment for alcohol-and drug-dependent patients, in outpatient or inpatient settings. It is sometimes but, overall, the literature is positive about the used as the sole source of treatment or combined merits of combining approaches. with individual counseling and other treatment One common type of psychotherapy for cocaine components. Researchers have acknowledged a dependence is supportive or supportive-expressive number of possible limitations to group therapy. psychotherapy. This therapy in combination with They include loss of confidentiality for the individ- pharmacotherapy has demonstrated some efficacy ual, likelihood of avoidance of group therapy be- in research with HEROIN-dependent persons. Ini- cause of social anxiety, and negative peer influ- tially, supportive psychotherapy focuses on ac- ences. knowledging the negative consequences of cocaine Research on the efficacy of group vs. individual use, accepting the need to stop using, and helping therapy alone or in combination continues. A Euro- manage impulsive behavior. The therapist and user pean reviewof 22 controlled outcome studies re- explore ways to stay away from other users and garding comparisons between individual and group high-risk environments. The focus of treatment psychotherapy treatments in general found that then shifts to insight-oriented psychotherapy in there is no superiority of one treatment over the which the therapist’s role is to facilitate the explo- other. The study noted, however, that group ther- ration of underlying reasons for the cocaine abuse. apy has an economic advantage over individual Long-term abstinence depends on the degree to therapy. Another study has shown that there are no which the underlying psychic disturbances are re- 1164 TREATMENT: Cocaine, Behavioral Approaches solved. A study from the 1990s has led some re- COGNITIVE AND searchers to conclude that low-intensity psycho- BEHAVIORAL THERAPY therapy was ineffective with the majority of their Behavioral perspectives of cocaine dependence subjects. viewdrug taking as a learned behavior that begins Interpersonal psychotherapy (IPT) was origi- and continues because of the reinforcing effects of nally developed for and found to be effective with the drug. These reinforcing effects are determined, DEPRESSION and was adapted for opiate addicts in part, by basic biological events in the brain. This and, later, cocaine abusers. This psychotherapy for means that, to some extent, most persons are sus- substance abusers is based on the premise that drug ceptible to becoming dependent because cocaine abuse is one way in which an individual attempts to produces a reaction in the brain that increases the cope with problems in interpersonal functioning. likelihood that drug taking will recur. The other An exploratory stance focuses on interpersonal re- factors that determine whether a person will be- lationships and the impact of drug abuse on these come dependent on cocaine are environmental fac- relationships. In helping the patient stop his or her tors (e.g., peers, acceptance by others, and no ap- substance abuse, the practitioner selects the impor- parent negative consequences). Research has tant components of treatment. They may include clearly demonstrated that cocaine seeking and use documenting the adverse effects of the drugs com- are learned responses that occur regularly under pared with their perceived benefits, identifying the specific conditions (e.g., certain times of day, thoughts and behaviors that precede drug use, and events, internal states). This outcome translates developing strategies to deal with drug-related cues into treatment that focuses on changing these ‘‘us- and high-risk situations. Only after attaining absti- ing’’ conditions and creating newconditions that nence are interpersonal difficulties directly ad- encourage abstinence from cocaine. dressed, including the roles of drug use in these Cognitive and behavioral therapy is a behavioral relationships. approach to treating cocaine dependence that is A key strategy with IPT is to develop more pro- often conducted through group therapy. The idea ductive means for achieving the desired social grat- behind the therapy is to make drug use less attrac- ification or tension reduction for which the drug tive and to create alternatives to drug use by chang- abuse substitutes. In a multiple drug abuser, this ing an individual’s internal and external environ- substitution may differ markedly for various drugs. ment. Some therapy is modeled on techniques that For example, the abuser may be using cocaine to individuals have used themselves to abstain from reduce social isolation and to ‘‘meet exciting new using or cut back on cocaine use. The approach attempts to help patients to recognize situations in people’’ but may be abusing alcohol because the which they are most likely to use cocaine, to avoid cocaine ‘‘crash’’ is reduced by the alcohol. Since these situations when appropriate, and to cope only the cocaine, and not the alcohol, is directly more effectively with problems and problematic related to the social deficit, only the cocaine abuse behaviors associated with drug abuse. For example, will directly benefit from interpersonal therapy. In individuals learn howto cope withboredom, anger, general, the interpersonal impact will be somewhat frustration, and depression, and howto handle so- different for the abuse of licit drugs such as alcohol, cial pressure to use drugs. Sometimes individuals illicit drugs such as heroin and cocaine, and drugs rehearse social situations in therapy sessions, to such as benzodiazepines. Among cocaine addicts, better equip them for handling such situations for example, the licit drugs such as alcohol are often when they encounter them. Individuals are also used in response to interpersonal tension, while the urged to give up other drugs, especially alcohol, illicit drugs such as heroin lead to consequences of because of its association with promoting cocaine increased interpersonal tension, rather than being use and its effect on weakening one’s resistance to used in response to tension. In summary, IPT must use. The possibility of a lapse is acknowledged in identify the relationship of each particular drug to this therapy and ways to deal with temporary the interpersonal setting as either primary associa- lapses in abstinence are covered so that the individ- tion or secondary to other drug effects and as either ual can work to prevent total relapse. Family and a tension reliever or inducer. friends are also encouraged to join therapy groups TREATMENT: Cocaine, Behavioral Approaches 1165 as many researchers believe that such support is tants, which include negative emotional states, in- one of the most effective ways to promote absti- terpersonal conflict, social pressure, and specific nence. Cognitive and behavioral therapy is consid- drug-related cues, may be quite different for differ- ered particularly useful because of its compatibility ent drugs of abuse. For example, in a methadone- with a range of other treatments patients may re- maintained patient, the precipitants for using her- ceive, such as pharmacotherapy. oin or cocaine may be closely related to being with A behavioral therapy component that is showing particular ‘‘friends’’ and then ‘‘getting high.’’ This positive results among many cocaine-addicted in- ‘‘getting high’’ on heroin can be pharmacologically dividuals is contingency management. Contingency blocked by large doses of METHADONE; large meth- management uses a voucher-based system to give adone doses will not have a similar effect on cocaine positive rewards for staying in treatment and re- use. Self-monitoring is used to identify risk situa- maining cocaine free. Based on drug-free urine tions for the specific drug, and then coping strate- tests, the patients earn points, which can be ex- gies are developed using rehearsal of coping behav- changed for items that encourage healthy living, iors such as anger management and social skills. such as joining a gym or going to a movie and Preventing relapse focuses on ensuring that brief dinner. Some vouchers can also be exchanged for lapses to cocaine use do not become full relapses. A retail goods. lapse may be seen as a discreet isolated event that is Another contingency-based method that some- not uncommon in recovery and that does not null- times works is CONTINGENCY MANAGEMENT. With ify all progress. Reduction of this ABSINENCE this method, the cocaine addict writes a letter that VIOLATION EFFECT by reframing the concept in this contains a damaging admission of cocaine use. The way may work with all drugs of abuse, although in addict then agrees that the letter can be made multiple-drug abusers, sequential lapses in each public if his or her urine shows up cocaine-positive drug must be prevented by carefully emphasizing after testing. Researchers believe that this type of the importance of abstinence and not giving ‘‘per- negative incentive may be effective among cocaine mission’’ for experimenting with isolated use of the users who have something to lose, as in good em- various abused drugs. ployment. Such incentive therapies have shown In the first test of its efficacy with cocaine depen- that cocaine use can be influenced by manipulating dence, RELAPSE PREVENTION was superior to IPT in the consequences of using. retaining individuals in treatment and in facili- Another behavioral approach focuses on the tating greater rates of cocaine abstinence. A second conditioned stimuli (environmental events) associ- trial of RPT provided additional support for its ated with cocaine use and the way those events efficacy. One-year follow-up data showed RPT to affect relapse and deter abstinence attempts. This be superior to case management in facilitating approach focuses intensely on the persons, places, higher levels of cocaine abstinence. In a study that and things that have frequently been paired with compared standard group counseling (STND) with cocaine use. Theoretically, things like drug-using individualized relapse prevention (RP), individuals friends, paraphernalia, white powder, and places who commited themselves to a goal of absolute where cocaine is used can produce cravings for abstinence on starting a continuing care program cocaine and ultimately result in cocaine use. There- had better cocaine use outcomes in RP than in fore, with repeated exposure to those events under STND. However, individuals with looser absti- conditions where cocaine is not available (i.e., an nence goals fared better with STND. extinction procedure), the events gradually lose Another two behavioral approaches, coping- their ability to elicit the cocaine craving and pre- skills training (CST) and neurobehavioral treat- sumably reduce the probability of cocaine use. ment, have received support as potentially effective One other behavioral approach that has received treatments. CST is similar to RPT in that it involves increasing attention is Relapse Prevention Treat- teaching specific drug refusal and coping skills im- ment (RPT), originally formulated for treating al- portant for accessing alternatives to drug use and cohol dependence. RELAPSE PREVENTION requires for coping with events that place the abuser at high specific interventions based on precipitants that risk. One year-long study found that during the have been identified as associated with the risk of first six months of the study individuals who had returning to abuse of a specific drug. These precipi- CST and relapsed used cocaine on significantly 1166 TREATMENT: Cocaine, Behavioral Approaches fewer days than did the control group using medi- more unilateral in focus. For example, behavioral tation and relaxation as a coping skill. The study approaches spend a great deal of time counseling was conducted in the context of high-risk situa- and assisting the abuser to make the behavioral tions. Both groups did equally well in the final 6 changes needed to achieve and maintain absti- months. nence. Eclectic approaches may spend only a small Neurobehavioral treatment emphasizes many of portion of time on those changes. The small time the elements of RPT and coping-skills training to spent focused on those changes may not be suffi- assist the abuser to abstain from cocaine and avoid cient to facilitate change, and it may give the relapse. The ‘‘neuro’’ prefix denotes specific treat- abuser the message that those changes are rela- ment focus on difficulties that may arise due to the tively unimportant. neurobiological changes that accompany abstinence from cocaine. CONCLUSIONS AND MOTIVATIONAL THERAPY FUTURE DIRECTIONS Researchers have noted a high dropout rate in There is no one treatment for cocaine abuse that most studies of addiction treatment and that of has proven more effective than any other. The those who do remain in treatment, most succeed in treatment of cocaine addiction is complex, and it breaking the habit. As a result of this success must address a variety of problems. Like any good among those who remain in treatment, some re- treatment plan, cocaine treatment strategies need searchers believe that the commitment to change to assess the psychobiological, social, and pharma- from addictive behavior is the greatest factor af- cological aspects of the patient’s drug abuse, and it fecting improvement in the cocaine-dependent in- is important to match the best treatment regimen to dividual. Motivational therapy takes advantage of the needs of the patient. Programs that provide this desire for change and is designed to help ad- several treatment options may prove the most ef- dicts realize the extent of their problem and help fective. increase their desire to quit. It also prepares them Evaluating programs for cocaine addiction has for other treatment. Motivational elements used in proven difficult. There are a number of limitations such therapy are described by the acronym inherent in many cocaine addiction studies that FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy). prevent researchers from drawing strong conclusions from the work; these limitations have included self-selection of treatment, the lack of uri- ECLECTIC TREATMENT nalysis data, insufficient follow-up time, a lack of Many treatment providers use an eclectic ap- independent evaluation, and the unreliable infor- proach to treat cocaine dependence; that is, a com- mation provided by the addicts themselves. bination of approaches. For example, many pro- Research continues on specific issues that may grams based on a disease or a psychodynamic influence treatment outcome. These issues include model may use certain behavioral procedures such (1) the use of other drugs including ALCOHOL, as contingency contracting or relapse prevention (2) the presence of other psychiatric problems, and strategies. (3) the severity and duration of the abuse. In gen- In a collaborative cocaine treatment study con- eral, researchers believe that recovery from cocaine ducted by the National Institute on Drug Abuse, addiction will be difficult unless the individual has researchers found that group drug therapy plus individual drug counseling was more effective than something to lose and unless the individual believes cognitive therapy plus GDC, supportive-expressive that he or she has the power to change and make therapy plus GDC, or GDC alone. positive choices. In general, a limitation of eclectic approaches is that mixed messages may be given to the patient. (SEE ALSO: Adjunctive Drug Taking; Causes of Sub- Moreover, the intensity and quality of each compo- stance Abuse; Disease Concept of Alcoholism and nent may not be as high as approaches that are Drug Abuse; Treatment Types) TREATMENT: Cocaine, Behavioral Approaches 1167

BIBLIOGRAPHY search Monograph no. 137. Washington DC: U.S. Government Printing Office. ANKER, A. L., & CROWLEY, T. J. (1982). Use of contin- HIGGINS, S. T., ET AL. (1991). A behavioral approach to gency contracts in specialty clinics for cocaine abuse. achieving initial cocaine abstinence. American Jour- In L. S. Harris (Ed.), Problems of drug dependence nal of Psychiatry, 148 1218–1224. 1981. NIDA Research Monograph no. 41. Washing- HIGGINS, S. T., ET AL. (1993). Achieving cocaine absti- ton, D.C.: U.S. Government Printing Office. nence with a behavioral approach. American Journal BUDNEY, A. J., HIGGINS, S. T., BICKEL,W.K.,&KENT.L. of Psychiatry, 150, 763–769. (1993). Relationship between intravenous use and KANG, S.-Y., ET AL. (1991). Outcomes for cocaine abus- achieving initial cocaine abstinence. Drug and Alco- ers after once-a-week psychosocial therapy. American hol Dependence, 32, 133–142. Journal of Psychiatry, 148, 630–635. CARROLL, K. M. (1993). Psychotherapy and phar- KLERMAN, G. L., ET AL. (1984). The theory and practice macotherapy for ambulatory cocaine abusers. Paper of interpersonal psychotherapy for depression. New presented at the NIDA Technical ReviewMeeting on York: Basic Books. Outcomes for Treatment of Cocaine Dependence, MARLATT, G. A., & GORDON, J. R. (1985). Relapse pre- September, Bethesda, MD. vention: Maintenance strategies in the treatment of CARROLL, K. M., ET AL. (1987). Psychotherapy for co- addictive disorders. NewYork: Guilford Press. caine abusers. In D. Allen (Ed.), The cocaine crisis. MCKAY, J. R., ALTERMAN, A. I., CACCIOLA, J. S., O’BRIEN, (pp. 75–105). NewYork: Plenum. C. P., KOPPENHAVER, J. M., & SHEPARD, D. S. (1999). CARROLL, K. M., ROUNSAVILLE, B. J., & GAWIN,F.H. Continuing care for cocaine dependence: comprehen- (1991). A comparative trial of psychotherapies for sive 2-year outcomes. Journal of Consulting and Clin- ambulatory cocaine abusers: Relapse prevention and ical Psychology, 67(3), 420–427. interpersonal psychotherapy. American Journal of NATIONAL INSTITUTE ON DRUG ABUSE. Innovative day Drug and Alcohol Abuse, 17, 229–247. treatment with abstinence contingencies and CHILDRESS, A. R., ET AL. (1993). Cue reactivity and cue vouchers. reactivity interventions in drug dependence treat- O’BRIEN, C. P., ET AL. (1990). Evaluation of treatment ment. In L. S. Onken, J. D. Blaine, & J. J. Boren for cocaine dependence. In L. S. Harris (Ed.), Prob- (Eds.), Behavioral treatments for drug abuse and de- lems of drug dependence 1989, NIDA Research Mono- pendence. NIDA Research Monograph no. 137. graph no. 95. Washington, D.C.: U.S. Government Washington DC: U.S. Government Printing Office. Printing Office. CRITS-CHRISTOPH, P., SIQUELAND, L., BLAINE, J., FRANK, RAWSON, R. A., ET AL. (1986). Cocaine treatment out- A., LUBORSKY, L., ONKEN, L. S., MUENZ, L. R., THASE, come: Cocaine use following inpatient, outpatient, M. E., WEISS, R. D., GASTFRIEND, D. R., WOODY, and no treatment. In L. S. Harris (Ed.), Problems of G. E., BARBER, J. P., BUTLER, S. F., DALEY, D., SAL- drug dependence 1985. NIDA Research Monograph LOUM, I., BISHOP, S., NAJAVITS, L. M., LIS, J., MERCER, no. 67. Washington, D.C.: U.S. Government Printing D., GRIFFIN, M. L., MORAS,K.,&BECK, A. T. (1999). Office. Psychosocial treatments for cocaine dependence: Na- RAWSON, R. A., ET AL. (1993). Neurobehavioral treat- tional Institute on Drug Abuse Collaborative Cocaine ment for cocaine dependency: A preliminary evalu- Treatment Study. Archives of General Psychiatry, ation. In F. M. Tims & C. G. Leukefeld (Eds.), Co- 56(6), 493–502. caine treatment: Research and clinical perspectives. FOOTE, J., DELUCA, A., MAGURA, S., WARNER, A., GRAND, NIDA Research Monograph no. 135. Washington DC: A., ROSENBLUM, A., & STAHL, S. (1999). A group U. S. Government Printing Office. motivational treatment for chemical dependency. ROHSENOW, D. J. (1993). Coping skills training for co- Journal of Substance Abuse Treatment, 17(3), 181– caine dependent individuals. Paper presented at the 192. NIDA Technical ReviewMeeting on Outcomes for HIGGINS,S.T.&BUDNEY, A. J. (1993). Treatment of Treatment of Cocaine Dependence, September, Be- cocaine dependence through the principles of behav- thesda, MD. ior analysis and behavior pharmacology. In L. S. On- ROHSENOW, D. J., MONTI, P. M., MARTIN, R. A., MI- ken, J. D. Blaine, & J. J. Boren (Eds.), Behavioral CHALEC, E., & ABRAMS, D. B. (2000). Brief coping treatments for drug abuse and dependence. NIDA Re- skills treatment for cocaine abuse: 12-month sub- 1168 TREATMENT: Cocaine, Pharmacotherapy

stance use outcomes. Journal of Consulting and Clini- TSCHUSCHKE, V. (1999, July-September). Individual cal Psychology, 68(3), 515–520. versus group psychotherapy—Equally effective? ROUNSAVILLE, B. J., GAWIN, F., & KLEBER, H. (1985). Gruppenpsychotherapie und Gruppendy- Intrapersonal psychotherapy adapted for ambulatory namik,35(4), 257–274. cocaine abusers. American Journal of Drug and Alco- STEPHEN T. HIGGINS hol Dependence, 11, 171–191. REVISED BY PATRICIA OHLENROTH SIMPSON, D. D., JOE, G. W., FLETCHER, B. W., HUBBARD, R. L., & ANGLIN, M. D. (1999, June). A national evaluation of treatment outcomes for cocaine dependence. Cocaine, Pharmacotherapy The Archives of General Psychiatry, 56(6), 507. pharmacological treatment of COCAINE abuse is de- SMELSON, D. A., ROY, A., SANTANA, S., & ENGELHART,C. fined as the use of medication to facilitate initial (1999, May). Neuropsychological deficits in with- abstinence from cocaine abuse and to reduce subse- drawn cocaine-dependent males. American Journal of quent relapse. The initiation of abstinence from Drug and Alcohol Abuse, 25. cocaine abuse involves reduction in the withdrawal STERLING,R.C.,GOTTHEIL,E.,GLASSMAN,S.D., symptoms associated with cessation of cocaine. WEINSTEIN, S. P., ET AL. (1997). Patient treatment This WITHDRAWAL syndrome resembles depression choice and compliance: Data from a substance abuse but includes a great deal of anxiety and craving for treatment program. American Journal on Addictions, cocaine. CRAVING for cocaine often persists for sev- 6(2), 168–176. eral weeks after abstinence has been attained, and WASHTON, A. M. (1987). Outpatient treatment tech- places or things associated with cocaine use in the niques. In A. M. Washton & M. S. Gold (Eds.), Co- past, called cues, can continue to stimulate cocaine caine: A clinician’s handbook. NewYork: Guilford craving for many months. Because of this persis- Press. tence of what is known as conditioned craving, WASHTON, A. M., GOLD, M. S., & POTTASH, A. C. (1987). relapse to cocaine abuse can occur after the patient Treatment outcome in cocaine abusers. In L. S. Harris has become abstinent. Preventing relapse is an im- (Ed.), Problems of Drug Dependence. NIDA Research portant function of medication treatment. Monograph no. 76. Washington, D.C.: U.S. Govern- An objective of the use of medications in cocaine ment Printing Office. dependence is to reverse changes that are caused in WEISS,R.D.,GRIFFIN,M.L.,GREENFIELD,S.F., the brain after chronic cocaine use. These brain NAJAVITS, L. M., WYNER, D., SOTO, J. A., & HENNEN, changes, called neuroadaptation, have been dem- J. A. (2000). Group therapy for patients with bipolar onstrated in animal models of cocaine dependence. disorder and substance dependence: Results of a pilot Chemical analyses of animal brains exposed to co- study. Journal of Clinical Psychiatry, 61(5), 361- caine chronically showabnormalities in the 367. NEUROTRANSMITTER receptors on brain cells. The WOODY, G. E., ET AL. (1983). Psychotherapy for opiate brain cell receptors that are affected by cocaine addicts: Does it help? Archives of General Psychiatry, include DOPAMINE receptors and SEROTONIN recep- 42, 1081–1086. tors (Harvard Mental Health Letter, December YAHNE, C. E., & MILLER, W. R. Enhancing motivation 1999). Neurotransmitters such as dopamine and for treatment and change. (1999). Addictions: A com- serotonin may be involved in the conditioned prehensive guidebook. NewYork: Oxford University craving that creates the risk of relapse. Researchers Press. 235–249. are also looking for hereditary factors that may COCAINE ABUSE AND ADDICTION. (1999, December). Har- determine individual differences in susceptibility, vard Mental Health Letter, 16. which may lie in genes that control the manufac- COCAINE DEPENDENCE. (1999, July 7). Clinical Reference ture of neurotransmitter receptors (Harvard Men- Systems, 300–302. tal Health Letter, December 1999). DISTINCTIVE FEATURE OF SHORT-TERM PSYCHODYNAMIC-IN- Direct and indirect evidence that there are TERPERSONAL PSYCHOTHERAPY:AREVIEW OF THE COM- changes in brain receptors can be found in human PARATIVE PSYCHOTHERAPY PROCESS LITERATURE. studies. Prolactin is a hormone that is controlled by (2000). Clinical Psychology: Science & Practice, the neurotransmitters dopamine and serotonin. In 7(2), 167–188. some heavy cocaine abusers, prolactin levels are TREATMENT: Cocaine, Pharmacotherapy 1169

abnormally high after abuse has stopped and re- vided a further rationale for the use of ANTIDEPRES- main elevated for a month or more. This evidence SANT medications in the treatment of cocaine de- suggests that both dopamine and serotonin brain pendence and withdrawal. systems are perturbed by cocaine and that the ab- A wide range of pharmacological agents besides normality persists for some time. Other evidence of antidepressants have been tried as treatments for persistent abnormalities in the dopamine systems cocaine abuse and addiction. In general, agents incomes from brain imaging studies directly examin- clude drugs that affect the production, release, re- ing dopamine receptors. Positron-emission tomog- absorption, and breakdown of dopamine, seroto- raphy (PET) studies have shown a marked reduc- nin, and other neurotransmitters (Harvard Mental tion in dopamine receptors on brain cells that are Health Letter, December 1999). Researchers are ordinarily very rich in such receptors. This abnor- also evaluating medications that work as a vaccine mally lowamount of dopamine receptors persists to prevent the effects of cocaine (Vaccine Weekly, for at least two weeks after a patient stops using May 4, 1998). cocaine. That several medications may reverse Combination pharmacotherapies are also being these neurochemical receptor changes has been an researched for cocaine-dependent individuals who important rationale for their use. abuse other substances. Multiple-drug abuse in co- In addition to direct biological indicators of caine abusers often involves problems with ALCO- neuroadaptation, neuropsychological tests have HOL,OPIOIDS and/or BENZODIAZEPINES. The medi- documented sustained deficits in thinking, concen- cal consequences of using these drugs in various tration, and learning among chronic cocaine abus- combinations are often more severe than using each ers. These deficits may persist for weeks after co- drug alone, and combinations of treatment options caine use has stopped. Researchers believe that may be needed for many of these drugs. Specific some neuropsychological deficits may be related to treatments may include pharmacotherapies tar- reduced blood flowto the brain in abusers. One geted toward cocaine as well as other drugs of PET study showed reduced cerebral blood flow in abuse, such as NALTREXONE for opioid abuse and patients that had been given cocaine (American DISULFIRAM for alcohol abuse. Opioid-derived med- Journal of Drug and Alcohol Abuse, May 1999). ications have also been explored. The use of opioid- The biological abnormalities in the brains of derived medications to treat cocaine dependence abusers clinically may be manifest by a characteris- has an ironic twist, because Sigmund Freud had tic withdrawal syndrome. The very early phases of suggested that cocaine might be an appropriate this syndrome, commonly called the ‘‘crash,’’ may treatment for morphine (an opioid) addiction. involve serious psychiatric complications, such as Clearly substituting one drug of abuse for another paranoia with agitation and depression with sui- drug of abuse is a risky treatment approach, but cide. These complications require medications for newideas are emerging on the use of opioids with symptomatic management, including ANTIPSYCHO- lower abuse potential than morphine, such as TIC agents, such as chlorpromazine and haloperi- BUPRENORPHINE for patients dependent on both dol, or large dosages of BENZODIAZEPINES to calm opioids and cocaine. highly agitated patients. Many patients self-medi- Evaluation of medications in controlled studies cate these crashes using such sedating substances using double blinding and random assignment is as benzodiazepines or alcohol. Because this crash very important, because a substantial placebo re- phase is usually relatively brief, rarely lasting more sponse may occur in cocaine abusers when they than several days, there is generally no role for enter treatment, even if they are given a simple sustained medication. The more important role for sugar pill. In double-blind, placebo-controlled medications occurs during the later phase of with- studies, neither the patient nor the physician knows drawal from cocaine, which may persist for several whether the patient is receiving active medication weeks. This later phase resembles a depressive syn- or placebo. Controlled studies provide the clearest drome, with substantial anxiety and craving to use indication of an efficacious medication when it is cocaine. The neurobiological changes noted in both found to be significantly better than a placebo human and animal studies after chronic cocaine given to similar patients in a randomized and use correspond in time to the occurrence of this blinded manner. Randomization simply means that syndrome. This temporal correspondence has pro- patients who are potential subjects for a study are 1170 TREATMENT: Cocaine, Pharmacotherapy randomly assigned to get either the active medica- MISCELLANEOUS AGENTS tion or the placebo. Choices about who will get A number of other agents have been utilized to active medication and who will get the placebo are treat different aspects of cocaine abuse and depen- made by chance alone and not decided by the phy- dence. Several authors report a decrease in eu- sician based on drug-abuse severity or any other phoria and/or paranoia with such neuroleptics criteria. In uncontrolled tests, patients are given the (ANTIPSYCHOTIC medications) as flupenthixol. medication and their response is compared with Neuroleptics are said to reduce the activity of dopa- their behavior before starting treatment. mine (Harvard Mental Health Letter, December 1999). Flupenthixol may be particularly useful as a ANTIDEPRESSANTS treatment for cocaine abusers with schizophrenia In controlled studies, several antidepressants (American Journal of Drug and Alcohol Abuse, Au- have been found superior to placebo. One such gust 1998). antidepressant was desipramine. Desipramine was Studies have begun on the development of a felt to promote cocaine abstinence by reducing cocaine vaccine designed to suppress the psychoac- craving. In one study of the efficacy of desipramine, tive effect of the drug. Such a vaccine works by cocaine use declined several weeks before cocaine producing antibodies that bind to cocaine in the craving was reduced. This delay suggested that bloodstream and prevent it from traveling to the desipramine reduced the recurrence of craving af- central nervous system, thus neutralizing the effect ter cocaine abstinence had been attained, and thus of the drug. Studies have found that it was possible its anticraving action might be more important for to override the effects of the vaccine with massive the prevention of relapse than for the initiation of amounts of cocaine, but researchers believe that abstinence. One pilot study suggested that another such consumption would be unlikely with addicts another antidepressant, venlafaxine, may be an ef- actively working to overcome addiction. Research- fective treatment for patients with a dual diagnosis ers have viewed the vaccine as a complementary of depression and cocaine dependence (American therapy to behavioral therapy. Journal of Drug and Alcohol Abuse, February 2000). MULTIPLE-DRUG USE According to the National Institute on Drug DOPAMINERGIC AGENTS Abuse, most cocaine-dependent people abuse other In theory, dopaminergic agents may be useful in substances. More than half are alcohol dependent. ameliorating early withdrawal symptoms after co- Opioid and sedative dependency has also been caine binges, because these agents appear to have widespread over the years. The reasons for cocaine their onset of action within a day of starting. These abuse by heroin addicts are to ‘‘improve’’ the eu- agents include AMANTADINE, bromocriptine, and phoria from heroin. These findings suggest that METHYLPHENIDATE. Bromocriptine has been stud- control of heroin abuse in many patients may di- ied by several groups of investigators and has rectly reduce cocaine abuse, and the reduction in shown efficacy for some and not for others. Several cocaine abuse reported by several surveys of meth- trials have examined amantadine at 200 and 300 adone-maintenance programs support this asser- milligrams (mg) daily and found that it reduces tion. craving and use for several days to a month. Meth- Combination pharmacotherapies of cocaine an- ylphenidate was shown effective in reducing co- ticraving agents with methadone or naltrexone for caine cravings in cocaine users with attention-de- heroin addiction and with disulfiram or naltrexone ficit/hyperactivity disorder (ADHD). One theory for alcoholism have been tried with some success. for addiction among ADHD cocaine abusers is that While buprenorphine, a mixed opiate agonist-an- they are medicating themselves. Methylphenidate tagonist, and methadone have been effective in acts on receptors like cocaine, but it acts much reducing opiate use, further studies are required to more slowly (Harvard Mental Health Letter, De- substantiate efficacy in reducing cocaine use in opi- cember 1999). Side effects have limited the utility ate addicts. However, one small study showed that of several other dopaminergic agents. buprenorphine in combination with desipramine or TREATMENT: Drug Abuse: 2000 and Beyond 1171

amantadine facilitated some cocaine abstinence. LOWINSON, J. H., RUIZ, P., & MILLMAN,R.B.(EDS.). Buprenorphine and disulfiram was also found more (1992). Substance abuse: A comprehensive textbook. effective than buprenorphine alone in treating her- Baltimore: Williams & Wilkins. oin addicts with a cocaine habit (Alcoholism and MILLER,N.S.(ED.). (1991). Comprehensive handbook Drug Abuse Weekly, June 19, 2000). Disulfiram is of drug and alcohol addiction. NewYork: Marcel used in the treatment of alcohol addiction, and Dekker. taking it before using cocaine may block the plea- NATIONAL INSTITUTE ON DRUG ABUSE. A community rein- surable effects of cocaine and invoke such negative forcement approach: Treating cocaine addiction. effects as anxiety and paranoia, effects that may Therapy Manuals for Drug Addiction. help discourage cocaine use (Alcoholism and Drug OLIVETO, A. H., FEINGOLD, A., SCHOTTENFELD, R., Abuse Weekly, June 19, 2000). The antidepressant JATLOW, J., & KOSTEN, T. Desipramine in opioid-de- desipramine also shows some promise in promoting pendent cocaine abusers maintained on opioid and cocaine abstinence in opioid-main- buprenorphine vs methadone. (1999, September). tained patients (Oliveto et al., September 1999). Archives of General Psychiatry, 56. An important clinical need with patients depen- SMELSON, D. A., ROY, A., SANTANA, S., & ENGELHART,C. dent on opiates, alcohol, or sedatives in addition to (1999, June). Neuropsychological Deficits in With- cocaine is for detoxification. While cocaine withdrawn Cocaine-Dependent Males. American Journal drawal is not associated with major medical com- of Drug and Alcohol Abuse, 25. plications, withdrawal from these other drugs can WEDDINGTON, W. W., ET AL. (1991). Comparison of am- be medically significant and often needs specific antadine and desipramine combined with psychother- pharmacological interventions. apy for treatment of cocaine dependence. American Journal of Drug and Alcohol Abuse, 17, 137–152. (SEE ALSO: Causes of Substance Abuse; Drug Me- ANTI-COCAINE VACCINE PRODUCES ANTIBODIES AND IS SAFE. tabolism; Research, Animal Model ) (2000, March 22). Vaccine Weekly. BUPRENORPHINE/DISULFIRAM EFFECTIVE FOR HEROIN/CO- BIBLIOGRAPHY CAINE ADDICTION. (2000, June 19). Alcoholism & Drug Abuse Weekly, 12. GAWIN, F. H., ET AL. (1989). Desipramine facilitation of COCAINE ABUSE AND ADDICTION—PART II. (1999). Har- initial cocaine abstinence. Archives of General Psychi- vard Mental Health Letter, 16. atry, 46, 117–121. NEW DRUG APPEARS ADVANTAGEOUS IN AIDING COCAINE JAFFE, J. H. (1985). Drug addiction and drug abuse. In WITHDRAWAL. (1999, August 2).Alcoholism & Drug A. G. Gilman et al. (Eds.), Goodman and Gilman’s Abuse Weekly, 11. the pharmacological basis of therapeutics, 7th ed. SEEKING WAYS TO CRACK COCAINE ADDICTION. (1998, Octo- NewYork: Macmillan. ber 17). The Lancet, 1290. KOSTEN, T. R. (1989). Pharmacotherapeutic interven- U.S. FIRM STARTS TESTS ON COCAINE VACCINE. (1998, May tions for cocaine abuse: Matching patients to treat- 4). Vaccine Weekly (18). ment. Journal of Nervous and Mental Disease, VENLAFAXINE TREATMENT OF COCAINE ABUSERS WITH DE- 177(7), 379–389. PRESSIVE DISORDERS. (2000, February). American KOSTEN, T. R., & KLEBER,H.D.(EDS.). (1992) Clini- Journal of Drug and Alcohol Abuse, 26. cian’s guide to cocaine addiction. NewYork: Guilford Press. THOMAS R. KOSTEN REVISED BY PATRICIA OHLENROTH LEVI, F. R., EVANS, S. M., MCDOWELL, D. M., & KLEBER, H. D. Methylphenidate reduces drug cravings in cocaine users with ADHD. (1999, January). The Brown University Digest of Addiction Theory and Applica- Drug Abuse: 2000 and Beyond Drug tion, 18. addiction is a medical and public health problem LEVIN, F. R., EVANS, S. M., COOMARASWAMMY, S., COL- that affects everyone, either directly or indirectly. A LINS, E. D., REGENT,N.,&KLEBER, H. D. (1998, recent study estimated that drug abuse and addic- August). Flupenthixol treatment for cocaine abusers tion cost the United States more than $110 billion with schizophrenia: a pilot study. American Journal of per year. If one adds the cost of nicotine to this Drug and Alcohol Abuse, 24. figure, the number dramatically soars. Improved 1172 TREATMENT: Drug Abuse: 2000 and Beyond prevention and treatment are the best ways to re- widely available to the public. For example, NIDA duce that cost. Fortunately, advances in science has taken the lead in developing readily available have revolutionized our fundamental understand- nicotine addiction therapies. They have also ing of the nature of drug abuse and addiction, and brought to the world the most effective medications what to do about it. to date for heroin addiction, including methadone Extensive data showthat addiction is eminently and LAAM (levo-alpha-acetylmethadol), and have treatable if the treatment is well delivered and standardized behavioral interventions that have tailored to the needs of a particular patient. There been effective in treating both adults and adoles- is an array of both behavioral and pharmacological cents. treatments that can effectively reduce drug use, NIDA supports research to develop additional help manage drug cravings and prevent relapses, newand improved pharmacological and behavioral and restore people as productive members of soci- treatments. To this end, NIDA sponsors both a ety. medications development program and a behav- Three decades of scientific research and clinical ioral therapies development program. NIDA’s med- practice have yielded a variety of effective ap- ications development program brings the critical proaches to drug addiction treatment. Extensive mass of knowledge of medicinal chemistry, molecu- data document that drug addiction treatment is as lar biology, brain function, and behavior to bear on effective as treatments for most other similarly the urgent public health problem of drug addiction chronic medical conditions. In spite of scientific to provide newmedications as an effective adjunct evidence that establishes the effectiveness of drug to conventional treatment by helping to stabilize abuse treatment, many people believe that treat- addict and allowthem to succeed in their overall ment is generally ineffective. In part, this is because treatment program. Specifically, newmedications of unrealistic expectations. Many people equate ad- are being researched to: diction with simply using drugs, and they therefore expect that addiction should be cured quickly and block the effects of abused drugs; permanently, and viewtreatment is a failure if it is reduce the craving for abused drugs; not. In reality, because addiction is a chronic dis- moderate or eliminate withdrawal symptoms; ease, the ultimate goal of long-term abstinence of- block or reverse the toxic effects of abused ten requires sustained and repeated treatment epi- drugs; sodes. or prevent relapse in persons who have been Drug-abuse treatment programs using medica- detoxified from drugs of abuse. tions and/or behavioral techniques can and do Because behavioral interventions are the most work. The most successful treatment programs are common, and sometimes the only, treatments ad- a complex mix of medical, psychosocial and reha- ministered to individuals with drug addiction, bilitation services that attempt to deal with the NIDA also has a robust behavioral therapies devel- unique needs of each individual. However, effec- opment program to complement its medications tiveness of treatment can differ because of complex portfolio. Researchers are working to develop new variables such as the type(s) of drug(s) to which a behavioral treatments for drug abuse and addiction person is addicted, the dysfunctional lifestyles of and enhance the efficacy of existing ones. Psycho- many addicts, and time and treatment resources therapies, behavior therapies, cognitive therapies, available to addicts and treatment personnel. Many family therapies, and counseling strategies are Americans affected by drug addiction have been among the approaches currently being studied un- restored to healthy and productive lifestyles der this program. Once these treatments are proven through appropriate treatment. to be safe and effective in small trials, they will be tested in larger and more diverse populations NEW AND IMPROVED TREATMENTS through NIDA’s newNational Drug Abuse Treat- The National Institute on Drug Abuse (NIDA) ment Clinical Trials Network. This network will has already made considerable progress in develop- enable the rapid, concurrent testing of a wide range ing a variety of effective behavioral and pharmaco- of promising science-based medications and be- logical addiction treatments and making them havioral therapies across a spectrum of real-life TREATMENT: Heroin, Behavioral Approaches 1173 patient populations, treatment settings, and com- ioral (e.g., having poor social skills) factors that are munity environments. typically the focus of psychological interventions. A variety of psychological treatments, often in CONCLUSION combination with pharmacological approaches, have demonstrated effectiveness in the treatment of Addiction is a treatable disease. However, there heroin abuse. The purpose of this article is to sur- is no ‘‘one size fits all’’ treatment program. Treat- vey the most prominent psychological interventions ment is typically delivered in outpatient, inpatient, currently used in the treatment of heroin abusers. and residential settings, all of which have been Following a brief discussion of the development of shown to be effective in reducing drug use and are heroin abuse, we describe the factors that lead peo- appropriate for a specific type of patient. Drug ad- ple to seek treatment, the range of problems that diction treatment can include behavioral therapy may be characteristic of heroin abusers, and the (such as counseling, cognitive therapy, or psycho- psychological treatments—including THERAPEU- therapy), medications, or a combination of both. TIC COMMUNITIES, motivational incentive therapies, Behavioral therapies, such as cognitive behavioral counseling, psychodynamic and cognitive-behav- coping skills treatment, offer addicts ways for ioral psychotherapies, family therapy, and SELF- coping with their drug cravings, teach them to HELP approaches. The chapter concludes with a avoid drugs and relapse, and help them deal with discussion of the effectiveness of these interven- relapse if it occurs. The best programs provide a tions. combination of therapies and other services, such as referral to other medical, psychological, and so- DEVELOPMENT OF HEROIN ABUSE cial services, to meet the needs of the individual Initial heroin use is motivated by curiosity and patient. the desire to use it without becoming addicted. ALAN I. LESHNER Heroin is injected into a vein (although it is sometimes inhaled), and the user experiences an immediate rush, characterized by feelings of relaxation Heroin, Behavioral Approaches Psy- and well-being. As use escalates, withdrawal symp- chological treatments are an important component toms (e.g., cramps, irritability) may appear as the of comprehensive drug-abuse treatment. Medica- drug is eliminated from the body. At this point, individuals may start using the drug both for its tions such as METHADONE can be used to address positive effects and for alleviating uncomfortable physical dependence and other biological aspects of withdrawal symptoms. Drug use may also be moti- addiction, but HEROIN abuse is also a disorder in- vated by an attempt to cope with feelings of volving maladaptive learned behavior that must be STRESS, hopelessness, or depression. Whatever the stopped and replaced by healthier behaviors. Psy- causes of initial use, the frequent and repeated chological therapies help drug abusers to under- acquisition of heroin soon becomes a priority; some stand their feelings and behaviors and to make addicted individuals may resort to illegal activity changes in their lives that will lead to ending drug (e.g., stealing; prostitution) to buy illicit drugs. In use and maintaining abstinence. Drug abusers also addition heroin abusers are often concurrently ad- EPRES may have psychiatric problems, such as D - dicted to ALCOHOL and/or other drugs, including SION and ANXIETY, and they may have problems COCAINE and BENZODIAZEPINES (e.g., Valium, interacting with other people or dealing with anger Zanax) that they may have started taking before or and frustration. These problems can also be ad- after they began using heroin. It is in the context of dressed by psychological therapies. In addition, this addictive lifestyle that heroin abusers come to heroin abuse is a chronic relapsing disorder (i.e., the attention of treatment providers. Heroin abus- many people who try to stop end up returning to ers are usually ambivalent about seeking treat- drug use). Relapse to drug use following treatment ment; they like taking drugs and have difficulty is commonly attributed to environmental (e.g., as- seeing any reason to stop. They are most likely to sociating with drug-using friends), psychological begin treatment following a crisis of some sort—a (e.g., feeling depressed or angry), and/or behav- legal, physical, family, financial, or job-related 1174 TREATMENT: Heroin, Behavioral Approaches problem caused by their drug use. They are typi- remain abstinent and to continue working on the cally referred to specific treatment sites by friends, lifestyle changes needed for long-term successful family, or the legal system, which may mandate outcomes. In this chapter, we will describe the treatment as a part of probationary sentences. The content of psychological interventions for heroin cost, location, and availability of treatment slots abuse independent of the settings in which they are are all factors that affect selection of treatment set- typically administered. ting. ASSESSMENT TREATMENT SETTINGS By the time drug abusers seek treatment, they Treatment for heroin dependence is offered in often have a number of problems that need to be publicly funded clinics that accept patients with solved, only the first of which is stopping drug use. limited resources, including those who receive pub- Within any treatment setting, comprehensive as- lic assistance. It is also treated in private programs sessment is essential to focus treatment on the areas that take patients with higher incomes and/or med- where change is needed. It is first important to ical insurance. Treatment for heroin abuse is often understand the types and amounts of drugs that are defined by the setting in which it is delivered, not typically taken in order to assess the severity of the by the actual content of treatment, which may or drug-abuse problem. Drug-use information is as- may not differ across treatment settings. For exam- sessed through the patient’s self-report and urinal- ple, outpatient and inpatient clinics may offer re- ysis testing. Urinalysis testing provides objective in- markably similar services for drug abusers. One formation about whether the individual has or has exception is the THERAPEUTIC COMMUNITY, where not used drugs recently and can also be used to the treatment philosophy and approach are verify the truthfulness of self-reports. An under- uniquely associated with long-term recuperation in standing of psychological and environmental fac- a residential setting. Treatments are also labeled tors that precede and follow drug use (e.g., when, with regard to the relative role of psychological where, and why drugs are taken; where and how versus pharmacological interventions used. With the drugs are acquired), known as a functional METHADONE MAINTENANCE, for example, counsel- analysis, is also necessary for the development of ing and psychotherapy are viewed as secondary, strategies to initiate abstinence and prevent re- although complementary, to the daily oral adminis- lapse. Evaluation of psychiatric disorders is essen- tration of methadone—a drug that replaces heroin tial for determining appropriate treatment inter- within the dependence mode. At the opposite end of vention. Depression and ANTISOCIAL PERSONALITY, the spectrum are residential therapeutic communi- for example, are quite common among heroin ties and TWELVE-STEP self-help programs, in abusers (Brooner et al., 1997). Some problems, which the entire intervention consists of social and however, such as depression, may go away when behavioral modeling, with no use of medications. drug use stops. Finally, social functioning, employ- Drug-abuse treatment may also be distinguished by ment history, and illegal activity all have implica- whether it is offered in a hospital versus a commu- tions for psychological interventions and treatment nity clinic outpatient setting. Outpatient clinics prognosis and need to be thoroughly assessed. In- usually emphasize psychological techniques, by deed, being employed and having good social sup- providing counseling and psychotherapy services. port (e.g., from a spouse who does not abuse drugs) Hospital chemical dependency units usually offer are excellent predictors of treatment success if they medical detoxification that involves prescribed are already present, and areas that need attention medications along with some combination of psy- in treatment if they are not. The ADDICTION SEVER- chological approaches. These detoxification ser- ITY INDEX (ASI; McLellan et al., 1992), a structured vices are important for helping heroin- dependent interview that assesses drug use, physical and emo- people make the transition to a drug-free state. tional health, employment, social support, and le- However, it is also important that they continue in gal status, is often used by clinicians and research- treatment at the same or another state program ers to evaluate the broad range of factors that are after the detoxification has been completed. Those related to drug abuse and may improve with treat- who follow this recommendation are more likely to ment. TREATMENT: Heroin, Behavioral Approaches 1175

PSYCHOLOGICAL AND BEHAVIORAL munity. The final stage, reentry (12–24 months), TREATMENTS OF HEROIN ABUSE focuses on preparing the patient to separate from the TC and rejoin the outside community. It is This section will survey common psychological expected that after leaving patients will establish and behavioral approaches to the treatment of her- their own households and obtain regular employ- oin abuse. Although each differs in regard to its ment or continue their education. In summary, TCs philosophy and goals, all share an interest in elimi- attempt to rehabilitate the drug abuser by instilling nating the drug use of the heroin abuser and the a whole new set of attitudes and behaviors that substitution of healthier behaviors. conform to those expected by a non-drug-abusing Therapeutic Communities. Therapeutic society. Treatment programs modeled after thera- communities (TCs) are long-term (6–24 month) peutic communities are becoming increasingly residential programs developed specifically for popular for implementation in prison systems. helping drug abusers change their values and be- Typically, prisoners with a drug-abuse history are haviors in order to sustain a drug-free lifestyle. The invited to join the program 6–12 months prior to assumption behind these communities is that drug their scheduled release date. In most successful abusers, who have typically been involved in a programs, involvement with residential treatment special illicit sub-culture for most of their lives, continues after release from prison, a time when need to learn how non-drug-abusing individuals prisoners most need help with reentering the com- function in society. The goal is to rehabilitate the munity and establishing a drug-free lifestyle. drug abuser into a person who can conform to Drug-Abuse Counseling. This intervention society’s values and goals, assume social and job approach is practiced in methadone maintenance responsibilities, and make contributions to the programs, where patients are required to see a community. During treatment, the drug abuser counselor throughout the course of treatment— lives in a special residential community with other and may also be provided in outpatient commu- drug abusers and with therapists who may be nity-clinic programs. Counselors are usually pro- ex-addicts in recovery. A behavioral shaping/in- fessionals with a college degree in counseling, al- centive system is set up so that desirable behaviors though ex-addicts who have personal experience are rewarded through community privileges and with recovery from drug abuse may also provide increased responsibilities. In addition, patients counseling. Counselors have several roles. First, learn through observing peers and staff, who serve they monitor treatment compliance (that the pa- as role models for appropriate behavior, sometimes tient is attending regularly and providing urine called ‘‘right living.’’ specimens for drug testing as requested), confront Patients progress through three stages. In the any violations of program rules, and enforce penal- first stage, orientation (0–2 months), the patient ties and privileges. Second, based on problems and assimilates within the therapeutic community by deficits identified during the assessment phase, attending seminars concerning the philosophy and counselors formulate a treatment plan that specifies rules of the program. The second stage is called goals for the patient. For example, a treatment plan primary treatment (2–12 months) and character- may contain recommendations to abstain from ized by increasing work responsibilities and group drug use, obtain employment, and participate in leadership roles. This stage includes three phases. self-help groups. Counselors work with their pa- In the first phase (2–4 months), patients conform tients using several strategies to implement such a to the TC policies by following the rules, engaging treatment plan. Goal setting helps patients learn to in low-level work assignments, and attending set reasonable goals that will lead to a responsible group meetings. By the second phase (4–8 drug-free life (e.g., finding a job, starting a bank months), patients work at more responsible jobs, account, obtaining a driver’s license) and to outline actively participate in group meetings, and begin to specific steps required to attain chosen goals. In assume the responsibility of a role-model for other problem-solving training, counselors and patients patients. In the third phase (8–12 months), pa- work together to address both immediate and long- tients engage in top-level jobs (e.g., coordinating standing problems in the patient’s life. The primary services in the program), colead support and treat- goal is for patients to learn the strategies for solving ment groups, and become social leaders in the com- everyday problems and for making decisions. Rec- 1176 TREATMENT: Heroin, Behavioral Approaches reational planning may be used to encourage pa- workers during a one-on-one interaction with the tients to engage in new social and recreational ac- patient, uses interpersonal skills to promote insight tivities that might substitute for their typical and behavior change. Psychotherapy was devel- lifestyle of searching for drugs or hanging out with oped for use with neurotic and emotional disorders, drug-using friends. Finally, counselors are expec- but has been adapted for use with drug abusers. ted to refer patients to other community-helping Several specific types of psychotherapy are prac- agencies for services that they cannot provide ticed by various therapists, depending on their themselves. For example, patients who are unem- training, with psychodynamic and cognitive-be- ployed may be referred to an employment-counsel- havioral being two prominent types. In each of ing service. In summary, counseling attempts to these therapies, comprehensive assessment, em- comprehensively address the problems of drug pathic listening, nonjudgmental understanding, abusers using practical, goal setting, and problem- and patience are necessary tools to help the patient solving techniques. become involved in a therapeutic relationship and Motivational Incentive Therapy. The goal of provide a context for behavior change. motivational incentive therapy is to offer a therapy Psychotherapy can also be practiced in groups, that can more effectively compete with the power- and group treatment is frequently defined as a ful enticement of drugs and make abstinence a separate type of treatment. Groups are a popular more attractive option. It does this by offering im- way to conduct treatment and may be found in mediate and tangible benefits to the addict for re- virtually any treatment setting, including hospital maining abstinent. In a motivational incentive pro- and outpatient chemical dependency programs, gram, drug abusers in treatment can earn points methadone programs, and therapeutic communi- that are worth money each time they submit a urine ties. The content of therapy, however, can vary sample that tests negative for specified drugs (e.g., widely from one group to another in the same way heroin and cocaine). The incentive program is de- that differing approaches are used for individual signed to promote sustained abstinence. To do this, psychotherapy. Regardless of therapeutic ap- the number of points earned for each consecutive proach, group therapies do differ from individual drug-free sample increases over time and ‘‘resets’’ therapies in some specific ways. Groups provide a to the original lower number if the patient relapses context for mutual empathy, encouragement, and to use and submits a drug-positive sample. In gen- support among people who share similar problems. eral, the more money that is offered, the more Patients in groups may benefit from the experience successful the incentive program. For example, in of others in solving these problems and by entering some of the most successful research programs, pa- reciprocal helping relationships. The interactions tients have been able to earn up to $1000 if they among group members also provide a context in remained continuously abstinent for 3 months. Al- which the therapist can facilitate improved social though this amount may seem high, it is reasonable skills for those who may need them. compared to the costs of continuing drug abuse to Psychodynamic Therapy. Psychodynamic therapy society. Patients like the incentive program because with heroin abusers employs supportive, analytical they can use the money earned to improve their life. techniques to explore heroin use and the addictive For example, they can pay bills or exchange gift experience from the patient’s point of view. Drug certificates for groceries and other retail items. The use is viewed as a symptom of underlying emo- incentive program is not intended to last indefi- tional problems and/or relationship difficulties. nitely; 3 to 6 months is typical. However, the pro- Thus, psychodynamic therapy rarely confronts or gram helps keep patients in treatment and pro- attempts to modify drug use directly, and for this motes abstinence. During periods of sustained reason, it is usually implemented after stable absti- abstinence engendered by an incentive program, nence from drugs has been achieved. Therapy fo- counselors and clients can work on making the cuses instead on the patient’s thoughts, feelings and lifestyle changes that will promote more enduring relationships (past and present) with parents, abstinence after the incentive program ends. spouse, friends, and other significant individuals— Psychotherapy. This type of psychological from which the therapist tries to identify common treatment, usually practiced by trained clinical patterns or themes. As therapy progresses, the ther- psychologists, psychiatrists, or psychiatric social apist-patient relationship becomes the focal point, TREATMENT: Heroin, Behavioral Approaches 1177 as this relationship often replicates themes from likelihood of returning to drug use. Based on this interactions with others, which the therapist points functional analysis, the cognitive-behavioral thera- out. The primary means of behavior change results pist and the patient decide which factors (e.g., from the patient recognizing these common, often thoughts, places, people) are most likely to sustain maladaptive, interaction themes and determining ongoing drug use or act as triggers for relapse dur- to change them. Thus, the goal of treatment is for ing abstinence; then specific treatments are based the patient to understand the origin and function of on this analysis (Carroll et al., 1994). their feelings and behavioral patterns, and to use Patients and therapists may work together to this awareness to change the manner in which they devise strategies for avoiding drug-using friends cognitively interpret, emotionally respond, and be- and staying away from places in which the patient haviorally interact with individuals in their envi- has bought and used drugs in the past. In some ronments. For example, a psychodynamic therapist cases, patients may even want to change their might observe that anger is a continuing theme in a phone numbers or move to new locations. In addi- patient’s life and be sensitive to situations when the tion to environmental changes, heroin abusers may patient shows anger toward the therapist. When be taught new skills designed to help them cope this happens, the therapist will help the patient with high-risk situations that could trigger relapse. understand the circumstances leading to the anger For example, patients who use drugs when they feel and relate these circumstances to other situations stressed may be taught specific relaxation tech- when the patient had been angry. Eventually, the niques that can counteract stressful feelings. Pa- patient and therapist might explore the origins of tients may also learn drug-refusal skills to handle the patient’s anger (perhaps toward his or her par- situations where they actually encounter drugs (al- ents) and the relationship between the patient’s an- though it is better to avoid such situations alto- ger and engaging in self-destructive behavior (e.g., gether) and to use specific strategies for coping with drug use). As the patient develops more adaptive situations in which the return to drug use is likely ways of coping with thoughts, emotions, and rela- (e.g., calling a nonusing friend; leaving the situations to others, heroin and other substance use be- tion; making an appointment with their therapist). comes less necessary and desirable. In summary, In addition, cognitive-behavioral therapists may psychodynamic therapy views long-term absti- address the patient’s thought patterns that precede nence from drug use as an indirect result of resolv- heroin use and call attention to dysfunctional ing the causes of drug use. In this way, it is believed thinking. For example, patients may have unrealis- that a more permanent cure will result. tic thoughts (‘‘I must be loved and accepted by Cognitive-Behavioral Therapy: Relapse Preven- everybody or else I am a failure and might as well tion. Cognitive-behavioral therapists are concerned use drugs’’) or illogical thoughts (‘‘I will never be with direct interventions that will change behavior able to stop using drugs because I am an addict’’). and thinking without necessarily requiring or ex- The cognitive-behavioral therapist aims to change pecting insights into the causes of behavior. Recog- negative cognitions to adaptive, positive thinking nizing that relapse is a serious problem in drug (‘‘I do not need everybody’s approval’’; ‘‘I can learn abuse, these therapy approaches have been specifi- to gain control over my behavior’’). cally adapted for use with heroin and other drug Sometimes a pervasive maladaptive behavior abusers in a therapy called RELAPSE PREVENTION, pattern underlies drug abuse that can be addressed to teach them the skills necessary to initiate and with a cognitive-behavioral approach. For exam- sustain abstinence (Marlatt & Gordon, 1985). A ple, with a patient who has trouble controlling an- functional analysis derived in the assessment phase ger and tends to use drugs after angry confronta- allows the therapist to understand the thoughts, tions, the cognitive-behavioral therapist may place behaviors, and environmental conditions that pre- the patient on an anger-control skills-training pro- cede and follow heroin and other drug use and to gram. The patient would be instructed to avoid help the patient recognize the environmental (e.g., situations likely to induce anger (e.g., confronta- drug-using friends), cognitive (e.g., irrational tions with a supervisor) and would be taught spe- thinking), emotional (e.g., anger), and behavioral cific strategies for dealing with potential anger- (e.g., starting arguments) factors that may either producing situations. For example, relaxation reduce the likelihood of stopping or increase the might be employed to gain control over anger. Fur- 1178 TREATMENT: Heroin, Behavioral Approaches ther, the patient might be taught new self-state- adopted by many treatment programs, and drug- ments to replace thoughts that have typically pre- abuse patients are often referred to self-help groups ceded feelings of anger (e.g., ‘‘It would be nice to as an adjunct to other treatments. Active members get a raise, but it isn’t the end of the world if I do of self-help groups attend frequent meetings, some not get it’’). In summary, cognitive-behavioral as often as once per day. At these meetings, mem- therapy focuses directly on behavior change with- bers speak to each other about their drug use and out expecting or requiring insight into the cause of drug-related problems; they offer mutual advice the problem. To the extent that underlying emo- and support without the help of any trained thera- tional and interactional dysfunctions often exacer- pists. bate drug use, however, both the cognitive-behav- The philosophy, treatment goals, and proce- ioral and the psychodynamic therapist will end up dures of self-help groups are contained in a book dealing with the same issues—albeit in slightly called The 12 Steps to Recovery. This book, often different ways. referred to as ‘‘The Big Book,’’ outlines a series of Family Therapy. Heroin abusers are often raised in tasks designed to promote abstinence and long- dysfunctional families and may replicate the mal- term recovery among alcoholics and drug abusers. adaptive behavior patterns learned from their fam- The first step in recovery is to admit that one has a ilies within their own personal and romantic rela- problem with drugs and/or alcohol and that outside tionships. In addition, the patient’s heroin abuse help is needed to solve the problem. The sources of may have had a disruptive effect on that family. help to be called upon are other group members These observations suggest the importance of in- and a higher spiritual power (e.g., God), who will cluding the family in the treatment process, and supply the spiritual strength necessary to stop drug this is particularly true for adolescents who become use. The twelve-step program also advocates spe- involved with drugs while still living with their cific practical changes in lifestyle; these revolve families. For older drug abusers, it is often difficult around regular and frequent attendance at group to involve the family in treatment, and family resis- meetings and concentration on the goal of absti- tance/avoidance is one of the first issues that the nence (e.g., remembering the motto ‘‘one day at a therapist must address. Family therapy is a special- time’’). Once stable abstinence is achieved, the ized type of psychotherapy that has its own meth- drug user is encouraged to restore relationships ods, in which practitioners must be trained. Thus, with friends and family that have been damaged by it is generally conducted by a psychologist or other former drug use. For some, however, the self-help health professional who has been trained in one of community becomes the primary source of friend- several specific familial treatment approaches. Al- ships and social support. though there are several theoretical perspectives to Sponsorship is another technique used to pro- family therapy (e.g., psychodynamic, cognitive-be- mote and sustain abstinence. Specifically, all group havioral, family systems, etc.), the goals of these members are encouraged to work with a sponsor types of interventions are to help the family recog- who is typically an older, long-standing, group nize maladaptive patterns of behavior, to learn bet- member who models appropriate behavior, guides ter ways of solving family problems, to better un- new members through the twelve-step process, and derstand each other’s needs and concerns, and to provides a source of support for the new member to identify and modify family interactions that may be turn to in times of crisis. Later, the new member helping to maintain drug use in the targeted family may sponsor someone else. To the extent that self- member (or members). help programs permit former drug abusers to re- Self-Help Groups. ALCOHOLICS ANONYMOUS ceive support from peers, associate with new (AA) was created in 1935 by recovering alcoholics groups of non-drug-using friends, and engage in so that alcoholics could help each other abstain. alternate recreational activities with newly devel- NARCOTICS ANONYMOUS (NA) and COCAINE ANONY- oped social contacts, the goals and even processes MOUS (CA) were later based on the tenets of AA but are similar to therapy. However, these goals are geared toward drug addictions. The newest group accomplished through group support and modeling is Methadone Anonymous (MA), which accommo- using a treatment plan laid out in the twelve-step dates drug addicts who use methadone. The core code rather than through formal meetings with a beliefs espoused by self-help groups are commonly professional therapist. TREATMENT: Heroin, Behavioral Approaches 1179

EFFECTIVENESS OF PSYCHOLOGICAL stay—but more patients tend to stay in methadone TREATMENTS FOR HEROIN ABUSE than in TC treatment. Finally, the success of drug- abuse treatment in general is better for patients An end to drug use is the primary outcome mea- who exhibit the fewest psychiatric symptoms and sure for evaluating the effectiveness of drug-abuse the greatest social stability (McLellan, 1983). treatment. Urine testing is usually included as a When evaluation focuses on treatment setting routine part of any drug-abuse treatment, to pro- rather than on treatment content, it becomes diffi- vide objective information on whether the treat- cult to determine which components of treatment ment is being successful at motivating the patient are responsible for outcome results. This is espe- to stop drug use and maintain abstinence. Changes cially true since treatment programs for heroin in criminal behavior, employment status, family abuse are typically comprehensive and mul- problems, and physical and emotional health are timodal, encompassing a variety of techniques that also relevant to understanding the effectiveness of may include psychological and behavioral inter- treatment. Many of these collateral difficulties im- ventions, medications, and self-help. The few well- prove once drug use is stopped, although more executed studies that have attempted to evaluate improvement would be expected in treatment pro- the impact of specific psychological interventions grams that offer services to specifically address on heroin abusers have been conducted with meth- these collateral problems. Using this array of out- adone maintenance programs. These studies have come measures, studies have been conducted to shown that methadone-maintenance treatment evaluate the relative efficacy of treatments for her- outcome is enhanced by a variety of psychological oin abusers. These studies have typically focused interventions, including counseling (McLellan et on the treatment setting rather than the content of al., 1988, 1993), individual psychotherapy treatment that is delivered within each setting. Fur- (Woody et al., 1983), family therapy (Stanton & ther, some treatment settings have received much Todd, 1982), cognitive-behavioral/relapse preven- more evaluation than others. Methadone mainte- tion aftercare (McAuliffe, 1990), and motivational nance and TCs, for example, have received lots of incentive/contingency management therapy (Hig- attention, whereas hospital chemical-dependency gins, et al., 1993; Petry, 2000; Silverman et al., programs have been infrequently evaluated and 1998) as evidenced by reduced drug use and crime, self-help programs have not been evaluated at all plus improved social and psychological function- (Gerstein & Harwood, 1990). ing. Large scale followup studies such as the TREAT- MENT OUTCOME PROSPECTIVE STUDY (TOPS), the SUMMARY DRUG ABUSE TREATMENT OUTCOME STUDY (DATOS), and the DRUG ABUSE REPORTING PRO- Research has shown that several different types GRAM (DARP), which have surveyed outcomes from of treatment for heroin abusers can be effective. methadone, therapeutic community, and outpa- Heroin abusers who enter treatment do better than tient modalities, have found that drug abusers who those who apply but do not follow through with enter treatment display less drug use and better treatment. Heroin abusers who remain in treatment social adjustment during and following treatment the longest achieve better treatment outcomes than than they did prior to treatment and also have those who drop-out early. In addition, heroin abus- better outcomes than groups of patients who ap- ers who exhibit the fewest psychiatric symptoms plied for treatment but never followed through and demonstrate the most social stability appear to (Hubbard et al., 1989: Simpson & Sells, 1990; benefit most from treatment. Finally, specific psy- Simpson & Curry, 1997). These studies also found chological interventions have enhanced the effec- that effectiveness does not seem to be related to tiveness of methadone maintenance treatment. As type of treatment but rather to duration of stay in previously noted, heroin abuse is a chronic, re- treatment. Several types of treatment can be effec- lapsing disorder: It appears that long-term treat- tive, but only with those patients who remain for ment and perhaps repeated treatment may be nec- prolonged periods of time. Thus, methadone main- essary to eliminate drug use and to successfully tenance and therapeutic-community treatments address the broad range of psychosocial difficulties produce similar degrees of success with those who that usually accompany this disorder. 1180 TREATMENT: Heroin, Pharmacotherapy

(SEE ALSO: Addiction: Concepts and Definitions; MCLELLAN, A. T., ET AL. (1993). The effects of psychoso- Causes of Substance Abuse; Coerced Treatment for cial services in substance abuse treatment Journal of Substance Offenders; Drug Testing and Analysis; the American Medical Association, 269, 1953–1959. Opioid Dependence; Opioid Complications and PETRY, N. M., (2000). A comprehensive guide to the Withdrawal; Tolerance and Physical Dependence; application of contingency management procedures Treatment, History of; Treatment Types; Wikler’s in clinical settings. Drug and Alcohol Dependence, 58, Pharmacologic Theory of Drug Addiction) 9–25. ROUNSAVILLE, B. J., ET AL. (1982). Heterogeneity of psy- BIBLIOGRAPHY chiatric diagnosis in treated opiate addicts. Archives of General Psychiatry, 39, 161–166. BROONER, R. K., KING, V. L., KIDORF, M., SCHMIDT,C. SILVERMAN, K., ET AL. (1998). Broad beneficial effects of W., & BIGELOW, G. E. (1997). Psychiatric and sub- cocaine abstinence reinforcement among methadone stance abuse comorbidity among treatment-seeking patients. Journal of Consulting and Clinical Psychol- opioid abusers. Archives of General Psychiatry, 54, ogy, 66, 811–824. 71-80. SIMPSON,D.D.,&SELLS, S. B. (1990). Opioid addiction CARROLL, K. M., ROUNSAVILLE, B. J., & KELLER,D.S. and treatment: A 12-year follow-up. Malabar, FL: (1991). Relapse prevention strategies for the treat- Robert E. Krieger. ment of cocaine abuse. American Journal of Drug and SIMPSON,D.D.,&CURRY, S. J. (1997). Special issue: Alcohol Abuse, 17, 249-265. Drug Abuse Treatment Outcome Study (DATOS). CARROLL, K. M., ET AL. (1994). Psychotherapy and phar- Psychology of Addictive Behaviors, 11, 211-337. macotherapy for ambulatory cocaine users. Archives STANTON,M.D.,&TODD, T. C. (1982). The family ther- of General Psychiatry, 51, 177-187. apy of drug abuse and addiction. New York: Guilford GERSTEIN, D. R., & HARWOOD,H.J.(EDS.) (1990). Press. Treating drug problems, Vol. 1. Washington, DC: STITZER, M. L., BIGELOW, G. E., & GROSS, J. (1989). National Academy Press. Behavioral treatment of drug abuse. In Treatments of HIGGINS, S. T., ET AL. (1993). Achieving cocaine absti- psychiatric disorders, Vol. 2. Washington, DC: Amer- nence with a behavioral apporach. American Journal ican Psychiatric Association. of Psychiatry, 150, 763–769. WOODY, G. E., ET AL. (1983). Psychotherapy for opiate HUBBARD, R. L., ET AL. (1989). Drug abuse treatment: A addicts: Does it help? Archives of General Psychiatry, national study of effectiveness. Chapel Hill: University 40, 639–645. of North Carolina Press. MAXINE L. STITZER MARLATT, G. A., & GORDON, J. (1985). Relapse preven- MICHAEL KIDORF tion. New York: Guilford Press. MCAULIFFE, W. E. (1990). A randomized controlled trial of recovery training and self-help for opiate addicts in Heroin, Pharmacotherapy HEROIN abuse New England and Hong Kong. Journal of Psychoac- has been a social problem for many years. Heroin tive Drugs, 22, 197–209. was trademarked after its first synthesis and use by MCLELLAN, A. T. (1983). Patient characteristics associ- the Bayer pharmaceutical company in Germany in ated with outcome. In J. R. Cooper et al. (Eds.), Re- 1898. It is derived from MORPHINE, the natural search on the treatment of narcotic addiction: State of alkaloid complex that is found in opium. Although the art. Rockville, MD: National Institute on Drug heroin is taken into the body by a number of routes, Abuse. the most common is injection. The rapid absorption MCLELLAN, A. T., ET AL.. The fiftieth edition of the Ad- of injected heroin into the bloodstream causes a diction Severity Index: Cautions, additions, and nor- large ‘‘high’’ and a ‘‘rush,’’ at first (before tolerance mative data. Journal of Sustance Abuse Treatment, 9, occurs), and all the heroin is absorbed by this route. 261–275. Another method, smoking heroin, has been MCLELLAN, A. T., ET AL. (1988). Is the counselor an called ‘‘chasing the dragon,’’ perhaps as an allusion ‘‘active ingredient’’ in substance abuse rehabilitation? to Chinese opium smoking; in this method, heroin Journal of Nervous and Mental Disease, 176, 423– is placed on a metallic foil and a match lit under it. 430. When the heroin vaporizes, the vapor is inhaled TREATMENT: Heroin, Pharmacotherapy 1181 through a straw; liquid heroin rolls around on the was gained from the careful observations and care- foil—hence the chase. A third method of heroin fully controlled studies of the researchers there. use, which waxes and wanes in popularity as the After incarceration, the addicts often returned to purity of illicit street heroin changes, is insufflation their towns of origin, and most of them turned back (snorting). This method minimizes the risks of in- to drug abuse. The resulting clinical observation travenous drug use, including blood-borne infec- has been that imprisonment alone (with no drugs tious diseases such as hepatitis and HIV/AIDS, but it available) is an ineffective treatment of heroin does not produce a rush because absorption into abuse. the bloodstream is slow. Heroin can also be injected Historically, many of the medications used to into a muscle or under the skin (known as skin treat heroin withdrawal in the general public have popping). been largely ineffective; in some cases, the cure has At first, heroin users have few lingering effects been worse than the disease. Among the numerous after a dose. The drug effects wear off after about ineffective treatments have been Thorazine, six hours. Over time, however, addicts develop tol- BARBITURATES, and electroshock therapy. In one erance to the dose and dependence on the drug. method, belladonna and laxatives were used, be- Addicts will begin using heroin because they see cause of the incorrect supposition that narcotics people (friends, family, peers, role models) using it needed to be ‘‘rinsed’’ from the bodily tissues in or because they feel a need to try it. As the fre- which they were stored. At one institution that used quency of use increases, they begin to experience this treatment, six of 130 addicts died during such withdrawal symptoms when they are not using the opiate detoxification. Commenting on these meth- drug. At this point, they are physically dependent ods, two of the researchers at Lexington noted: on heroin and will require larger and larger doses of ‘‘The knockout feature of these treatments . . . heroin to achieve the same high or any high at all. doubtless had the effect of holding until cured Many addicts report that tolerance develops to such many patients who would have discontinued a an extent that they cannot use enough for a high withdrawal treatment before being cured, and the but must continue to use it to just feel normal (i.e., psychological effect of doing something for patients not be in withdrawal). It takes several weeks for a practically all the time has a tendency, by allaying naive user to become dependent with this type of apprehension, to hold them even though what is regular use. done is harmful’’ (Kolb & Himmelsbach, 1938). Since the research conductetd at Lexington from the 1930s to the 1950s, which showed that opiate HISTORICAL OVERVIEW withdrawal was not fatal (unless complicated by OF TREATMENTS other disorders or treatments), more standardized When heroin was first commercially marketed methods of detoxification have been developed. by the Bayer Company as a morphine-like cough A true advance was the development of metha- suppressant, it was thought to have fewer side ef- done as a long-acting, orally effective opioid. Meth- fects than morphine. It was also used in the ‘‘treat- adone was developed in Nazi Germany and was ment’’ of morphine addiction since it enters the given the trade name Dolophine by the Eli Lilly brain more rapidly than does morphine. Instead, company (from dolor, pain). The advantages of heroin introduced a new, more potent addiction. methadone over heroin include methadone’s effec- An over-the-counter industry in the legal sale of tiveness when taken by month; its long action, morphine and codeine elixirs also existed until opi- which allows single daily doses; and its gradual ates were outlawed by the HARRISON NARCOTICS onset and offset, which prevents the rapid highs ACT of 1914 and subsequent laws were passed dur- and withdrawal seen with heroin. Methadone- ing World War I (1914–1918). maintenance treatment was developed in the 1960s Treatment of heroin abuse in the United States in New York City and has become an accepted was initially targeted at removing the drug user treatment for opioid dependence. With the discov- from the environment of use. The federal prison in ery that HIV infection can be transmitted by intra- Lexington, Kentucky, became the site where incar- venous drug users, the benefits of methadone in cerated heroin addicts in federal custody were sent. decreasing intravenous heroin use have become Much of the current knowledge about opiate abuse even more evident. 1182 TREATMENT: Heroin, Pharmacotherapy

PHARMACOLOGICAL TREATMENT priate dose of methadone, which treats the with- APPROACHES drawal symptoms. They are monitored for overse- dation due to methadone or undermedication of The most common and first-line treatment ap- withdrawal symptoms. Intravenous users of street proach is to try to get the addict to stop using heroin heroin admitted to the hospital usually tolerate well by detoxification. Detoxification refers to using a starting methadone dose of 25 milligrams. The medications to treat withdrawal symptoms. The methadone dose is then gradually lowered over the heroin withdrawal symptoms are similar to the next several days. It is typical to taper a starting symptoms of a severe flu. Although these with- methadone dose of 25 milligrams over a period of drawal symptoms are rarely medically dangerous seven days. for those in good health, they are extremely uncom- Another approach avoids the difficulties of pre- fortable, and, in many addicts, they make the alter- scribing an opioid to an addict. It involves using the native, using heroin, more attractive than detoxifi- antihypertensive CLONIDINE to treat withdrawal cation. Severe withdrawal is associated with signs symptoms after the addict has stopped using the of sympathetic nervous system arousal as well as opiates. Clonidine suppresses many of the physical increased pulse, blood pressure, and body tempera- signs of opiate withdrawal, but it is less effective ture. Addicts experience sweating, hair standing on against many of the more subjective complaints their arms (i.e., gooseflesh—hence the expression during withdrawal such as lethargy, restlessness, ‘‘cold turkey’’), muscle twitches (from which the and dysphoria. Clonidine’s side effects of low blood expression ‘‘kicking the habit’’ comes), diarrhea, pressure, sedation, and blurry vision make it un- vomiting, insomnia, runny nose, hot and cold pleasant to take and unlikely to be abused by flashes, and muscle aches. A host of psychological addicts. Although clonidine has not been approved symptoms accompany the withdrawal distress. Af- by the Food and Drug Administration for opiate ter addicts have been detoxified, they may be detoxification, it is widely used for this purpose and treated with medications that make it less likely has demonstrated efficacy. It is most effective when they will use heroin again; these medications that used in addicts who are not addicted to large doses prevent relapse may work by blocking heroin’s ef- of opioids. fects. Medications can also be used to treat under- Opiate Antagonists. The opiate antagonist lying psychiatric problems that contributed to the NALTREXONE is used clinically to accomplish rapid addict’s use of drugs. detoxifications and to help detoxified addicts stay An alternative approach is METHADONE MAINTE- off opioids. Naltrexone binds more strongly than NANCE, which does not initially aim to stop the heroin to the specific brain receptors to which her- addict from using opioids but instead to substitute oin binds. If, therefore, addicts who are dependent oral methadone use for heroin abuse. Methadone is on heroin take a dose of naltrexone, the naltrexone a clear liquid, usually dissolved in a flavored drink, will replace the heroin at the brain receptor and the that is given once a day and is prescribed by a addicts will feel as if all the heroin has been sud- physician. Used as a way to treat addicts’ with- denly taken out of their body. The effect of this drawal symptoms and drug craving, the prescrip- rapid reduction in effective heroin (at the receptor) tion of methadone is closely controlled by state and is withdrawal. The withdrawal is usually more se- federal regulations. vere than that which comes from simply stopping Opiate Detoxification. The simplest ap- the heroin, but it also has the effect of accom- proach to detoxification is to substitute a prescribed plishing a detoxification more quickly. Thus, a opioid for the heroin that the addict is dependent combination treatment of clonidine to suppress the on and then gradually lower the dose of the pre- intensity of withdrawal symptoms and naltrexone scribed opioid. This causes the withdrawal to be to accelerate the pace of withdrawal has been used less severe, although the withdrawal symptoms for rapid detoxification. may last longer. A typical procedure entails first Naltrexone is primarily used after detoxification verifying that addicts are dependent on opioids (by to prevent addicts from returning to opioid use. some combination of observed withdrawal, a with- Because naltrexone binds to opioid receptors more drawal response to naloxone, or evidence of heavy tightly than does heroin, opioid addicts on naltrex- opioid use). The addicts are then given an appro- one who use heroin will find the heroin effect TREATMENT: Heroin, Pharmacotherapy 1183 blocked by naltrexone. Addicts maintained on nal- from methadone, the methadone side effects, and trexone who use heroin will only be wasting their the possibility of increased use of other illicit drugs money. One effect of naltrexone is thus to extin- such as cocaine. guish the conditioned response to heroin injection. An opiate addict initially coming in for treat- Naltrexone is prescribed in the form of a pill that ment will usually be put through detoxification and can be given as infrequently as three times a week. possibly put on naltrexone maintenance. Addicts It has few side effects in the majority of patients with intact family supports, good jobs, or strong who take it, and, contrary to some rumors, it does motivation are more likely to benefit from naltrex- not suppress other ‘‘natural highs.’’ one maintenance than those who are more im- Opioid Maintenance. Methadone is the most paired. Younger addicts and adolescents are urged common opioid used for the maintenance treat- to try nonmethadone approaches, so as to avoid ment of opioid addicts. Methadone satiates the her- developing a methadone addiction. Methadone oin user’s craving for heroin in order to prevent maintenance is usually reserved for patients who heroin withdrawal. The more important therapeu- have failed at previous detoxifications. An excep- tic effect of methadone, however, is tolerance to it. tion is made for pregnant women, in whom metha- Addicts maintained on a stable dose of methadone done maintenance is the treatment of choice, with do not get high from each dose because they are detoxification of the infant from methadone accom- tolerant to it. This tolerance extends to heroin, and plished after birth. Opiate detoxification is risky in methadone-maintained addicts who use heroin ex- pregnant women because of the adverse effects on perience a lesser effect because of the tolerance. fetal development in the first and second trimesters, Tolerance accounts for the fact that methadone- and the risk of miscarriage. maintained addicts can take methadone doses that Other nonmethadone medications for mainte- would cause a naive (i.e., first-time) drug user to nance treatment of opioid dependence have not yet die of an overdose. Generally, methadone-main- been widely used. BUPRENORPHINE is a partial opi- tained addicts do not appear to be either intoxi- oid agonist medication that has the advantages of cated or in withdrawal. Tolerance is admittedly being safe, even at higher doses, and being associ- incomplete, and methadonemaintained addicts ated with less severe withdrawal symptoms than have some opioid side effects that they do not be- methadone after discontinuation. Another medica- come tolerant to—for example, constipation, ex- tion recently approved for treating opioid depen- cessive sweating, and decreased libido. There is no dence is LAAM (levo-alpha-acetylmethadol). known medical danger associated with methadone LAAM is broken down in the body to very long- maintenance, however. acting active metabolites, and therefore it can be Methadone is dispensed as part of licensed pro- prescribed as infrequently as three times a week. grams, usually on a daily basis. It is generally well received by addicts, and the risk of incurring with- THE INTEGRATION OF drawal symptoms if methadone treatment is inter- PHARMACOLOGICAL AND rupted provides a strong incentive for addicts to PSYCHOSOCIAL TREATMENTS keep appointments. The ritual of daily clinic attendance has the additional therapeutic benefit of No medication will prevent an addict who wants beginning to impose structure on the chaotic lives to use heroin from doing so. Naltrexone mainte- of most opiate addicts. Methadone treatment is of- nance can be discontinued, and addicts who dis- ten augmented with medical, financial, and psy- continue it are able within one to three days to use chological support services to address the many heroin without the naltrexone blockade. Similarly, needs of opioid addicts. methadone maintenance is ineffective in addicts Despite the philosophical debates about the ap- who are unable or unwilling to meet the require- propriateness of using methadone, there is a large ments of clinic attendance (which sometimes re- body of evidence indicating that methadone-main- quires payment of fees) and staying out of prison. tained addicts show decreases in heroin use, crimes Addicts whose lives are in disarray require medica- committed, and psychological symptoms. The tions as part of a comprehensive treatment pro- major drawbacks to methadone maintenance in- gram that also addresses their other needs. In a clude the great difficulty of achieving detoxification street addict who chronically uses drugs, these may 1184 TREATMENT: Marijuana, An Overview

include needs for counseling, medical attention, vo- BIBLIOGRAPHY cational rehabilitation, and a host of other services. BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck There is evidence that methadone treatment is Manual of Diagnosis and Therapy, 17th ed. more effective if a higher ‘‘dose’’ of psychosocial Whitehouse Station, NJ: Merck Research Laborato- treatment is provided along with it. ries. Detoxification is a first step toward recovery BROPHY, J. J. (1994). Psychiatric Disorders. In L. M. because it makes the addict available to further Tierney et al. (Eds.), Current Medical Diagnosis & psychosocial and medical treatments. There is evi- Treatment, 33rd ed. Norwalk, CT: Appleton & dence that mild physiological abnormalities due to Lange. withdrawal of opiates linger for as long as three KOLB, L., & HIMMELSBACH, C. K. (1938). Clinical studies months after detoxification. This ‘‘long-term absti- of drug addiction. III. A critical review of the with- nence syndrome’’ is thought to contribute to the drawal treatments with methods of evaluating absti- craving for opiates that occurs after detoxification. nence syndromes. Public Health Reports, 128(1). Naltrexone maintenance is most effective in addicts Cited in H. D. Kleber (1981), Detoxification from who have jobs and stable social supports—for ex- narcotics. In J. H. Lowinson & P. Reiz (Eds.), Sub- ample, in anesthesiologists who have become ad- stance abuse: Clinical problems and perspectives. dicted to hospital medications. Because naltrexone Baltimore: Williams & Wilkins. itself is not reinforcing and many heroin addicts GREENSTEIN, R. A., ARNDT, I. C., MCLELLAN, A. T., have a host of psychosocial problems, many clinics O’BRIEN, C. P., & EVANS, B. (1984). Naltrexone: a have reported that naltrexone maintenance alone clinical perspective. Journal of Clinical Psychiatry, was minimally effective in the treatment of long- 45(9 Pt 2), 25–28. term addicts. O’BRIEN, C. P. (1996). Drug addiction and drug abuse. In J. G. Hardman et al. (Eds.), Goodman and Gilman’s The Pharmacological Basis of Therapeutics, SUMMARY 9th ed. New York: Mc-Graw-Hill. Opioid addiction is, in many ways, a physical O’BRIEN, C. P., CHILDRESS, A. R., MCLELLAN, A. T., problem as well as a psychological and behavioral TERNES, J., & EHRMAN, R. N. (1984). Use of naltrex- problem. Addicts become physically addicted to one to extinguish opioid-conditioned responses. Jour- nal of Clinical Psychiatry, 45(9 Pt 2), 53–56. opiates and, in the later stages of addiction, become SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES preoccupied with relieving the physical symptoms ADMINISTRATION (SAMHSA). (1999). 1998 National of withdrawal. They become highly attuned to the Household Survey on Drug Abuse. Washington, DC: bodily signals that withdrawal is coming. Heroin U.S. Department of Health and Human Services. addicts spend most of their waking life procuring, WILSON, B. A., SHANNON, M. T., & STANG, C. L. (Eds.) using, and withdrawing from heroin—three times a (1995). Nurses Drug Guide, 3rd ed. Norwalk, CT: day, seven days a week, fifty-two weeks a year—for Appleton & Lange. years. MARC ROSEN The medications used to treat opioid abuse are REVISEDBY REBECCA J. FREY powerful agents that interrupt this cycle. Although medications alone rarely cure an addiction, they are critically important to breaking the cycle of Marijuana, An Overview Although preoccupation with opioid use and enabling addicts marijuana is the most widely used illicit drug in the to benefit from comprehensive drug-abuse treat- U.S., fairly little is known about how to effectively ment. treat individuals who become dependent on this drug. Increasingly, however, the findings of con- (SEE ALSO: Coerced Treatment for Substance Of- trolled trials designed to evaluate the effectiveness fenders; Ibogaine; Opioid Dependence; Opioid of alternative counseling approaches are appearing Complications and Withdrawal; Pregnancy and in the literature. Additionally, recently acquired Drug Dependence; Substance Abuse and AIDS; knowledge about the actions of a marijuana-like Treatment Types) compound that occurs naturally in the brain will TREATMENT: Marijuana, An Overview 1185 enhance our understanding of the nature of mari- ducted since the mid-1980s have focused on evalu- juana dependence and possibly set the stage for the ating interventions for marijuana-dependent development of pharmacological interventions. adults. Stephens and Roffman (1994), in a 1986– Prevalence of Marijuana Dependence. The 1989 study funded by the National Institute on most widely used illicit substance in the U.S., it is Drug Abuse, compared the effectiveness of a estimated that seventy-two million people have 10-session cognitive-behavioral group intervention ever used the drug and eleven million are doing so with a 10-session social support group discussion currently (i.e., at least once in the past month). condition. The cognitive-behavioral treatment fo- Nearly seven million reported using marijuana cused on strengthening the participant’s skills in weekly or more often in 1998, and approximately effectively coping with relapse vulnerabilities. The two million individuals begin use of marijuana each social support treatment emphasized the use of year (SAMHSA, 1999). group support for change. The participants were Epidemiological studies conducted in the last 212 marijuana smokers who averaged over ten two decades permit an estimation of the prevalence years of near daily marijuana use. Following the of marijuana dependence in the United States. In completion of treatment and for the next 2.5 years the 1980s, the Epidemiological Catchment Area in which participants were periodically reassessed, (ECA) study involved in-person interviews with there were no significant differences between con- 20,000 Americans in five urban areas (Anthony & ditions in terms of outcomes (abstinence rates, days Helzer, 1991). The study’s purpose was to deter- of marijuana use, problems related to use). During mine the prevalence of psychiatric symptoms for the final two weeks of counseling, 63 percent of the forty major psychiatric diagnoses including drug total sample reported being abstinent. While only abuse and dependence. Based on the criteria for the 14 percent were continuously abstinent after one marijuana dependence diagnosis utilized in that year, 36 percent had achieved improvement (i.e., study (indications of tolerance or withdrawal plus either abstinence or reduction to 50 percent or less pathological use or impaired social functioning of the baseline use level and no reported mari- lasting for at least one month), 4.4 percent of adults juana-related problems) at that point. At 30 were found to have been dependent on marijuana months post-treatment, 28 percent reported absti- at some point in their lives. About a decade later, nence for the past 90 days. Thus, both counseling interviews conducted with over 8,000 individuals approaches were modestly effective in helping a for the National Comorbidity Study led to a very significant portion of participants either achieve similar estimate that 4.2 percent of the general U.S. abstinence or improvement. These findings called population meet the diagnostic criteria of mari- into question the hypothesized superiority of a cog- juana dependence (Anthony, Warner, & Kessler, nitive-behavioral approach with marijuana-depen- 1994). dent adults and argued for additional research on For those who have used marijuana at least treatment approaches. once, the relative probability of ever becoming de- In a second NIDA-funded study conducted by pendent on the substance is estimated at 9 percent Stephens and Roffman (1989–1994) with 291 (Anthony, Warner, & Kessler, 1994). This risk adult daily marijuana smokers, a three-group de- level appears modest when compared with risk esti- sign permitted the comparison of two active treat- mates of dependence for those who’ve used other ments with a delayed treatment control condition substances at least once (tobacco-32%; alcohol- (Stephens, Roffman, & Curtin, in press). One of the 15%; cocaine-17%; heroin-23%). However, active treatments involved 14 cognitive-behavioral among individuals who have smoked marijuana skills training group sessions over a four-month more frequently, the risk of developing dependence period, emphasizing both the enhancement of is higher. Among those who’ve used it five or more coping capacities in dealing with situations pre- times, the risk of dependence is 17 percent (Hall, senting high risk of relapse and the provision of Johnston, & Donnelly, 1999). For daily or near additional time for the building of group cohesion daily users, the risk may be as high as one in three and mutual support. The second active treatment (Kandel & Davies, 1992). involved two individual motivational enhancement Treatment Approaches with Marijuana-De- counseling sessions delivered over a one month pe- pendent Adults. A series of controlled trials con- riod. The latter approach appeared promising inas- 1186 TREATMENT: Marijuana, An Overview much as a growing literature in the addiction treat- produced outcomes superior to the 4-month de- ment field was supporting the effectiveness of layed treatment control condition. Further, the short-term interventions (Bien, Miller, & Tonigan, 9-session intervention produced significantly 1993), utilizing motivational interviewing strate- greater reductions in marijuana use and associated gies (Miller & Rollnick, 1991), designed to negative consequences compared to the 2-session strengthen the individual’s readiness to change intervention. Abstinence rates at the 4- and 9- (e.g., providing participants normative comparison month follow-ups for the 9-session intervention data concerning their marijuana use patterns). The were 23 percent and 13 percent, respectively. first session in this condition involved the counselor These differences between the two active treat- reviewing with the participant a written Personal ments were apparent as early as 4 weeks into the Feedback Report generated from data collected treatment period and were sustained throughout during the study’s baseline assessments. The coun- the first nine months of follow-up. As was the case selor used this review as an opportunity to seek in the two studies discussed above, the findings of elaboration from the participant when expressions the CSAT-funded research point to modest efficacy of motivation were elicited, to reinforce and of counseling interventions with marijuana-depen- strengthen efficacy for change, and to offer support dent adults. More positive outcomes from the 2-ses- in goal-setting and selecting strategies for behavior sion motivational enhancement intervention were change. One month later, the second session af- found in the Stephens and Roffman (in press) study forded the opportunity to review efforts and coping than in the CSAT-funded investigation. skills utilized in the interim period. In both condi- In a study funded by NIDA, Budney and col- tions, participants had the option of involving a leagues randomly assigned sixty marijuana-depen- supporter. Following treatment, there was no evident adults to one of three 14-week treatments: dence of significant differences between the two motivational enhancement, motivational enhance- active treatments in terms of abstinence rates, days ment plus coping skills training, or motivational of marijuana use, severity of problems, or number enhancement plus coping skills training plus of dependence symptoms. At the 16-month assess- voucher-based incentives (Budney, Higgins, ment, 29 percent of group counseling participants Radonovich, et al., in press). In the latter condition, and 28 percent of individual counseling partici- participants who were drug abstinent— pants reported having been abstinent for the past documented with twice-weekly urinalysis screen- 90 days. Both active treatments produced substan- ing—received vouchers that were exchangeable for tial reductions in marijuana use relative to the retail items (e.g., movie passes, sporting equip- delayed treatment control condition. The results of ment, educational classes, etc.). The value of each this study suggest that minimal interventions may voucher increased with consecutively negative be more cost-effective than extended group coun- specimens. Conversely, the occurrence of a can- seling efforts for this population. nabinoid-positive urine specimen or failure to sub- The third study, funded by the Center for Sub- mit a sample led to a reduction of each voucher’s stance Abuse Treatment (1996–2000) and con- value to its initial level. Participants in the voucher- ducted in three sites, also employed a three-group based incentive condition were more likely to design with a delayed treatment control condition achieve periods of documented continuous absti- (Donaldson, 1998). One of the active treatments nence from marijuana during treatment than were involved nine individual counseling sessions de- participants in the other two conditions. Addition- livered over a 12-week period, with the initial ses- ally, a greater percentage of participants in the sions focusing on motivational enhancement and voucher-based condition (35%) were abstinent at the later content emphasizing cognitive-behavioral the end of treatment than was the case in the skills skills training and, as needed, case management. training (10%) or motivational enhancement (5%) The other active treatment involved two individual conditions. The absence of long-term post-treat- motivational enhancement therapy sessions de- ment assessment data limits comparisons of this livered over a one-month period. (This condition study’s outcomes with those from the other trials replicated the brief intervention in the above-re- discussed above. However, based on their earlier ported study conducted by Stephens and Roffman). research with voucher-based incentives in treating At the 9-month follow-up, both active treatments cocaine-dependency, the authors are hopeful that TREATMENT: Marijuana, An Overview 1187 future studies will demonstrate successful long- (Stephens, et al., 1998). Project publicity targeted term outcomes in marijuana-dependent partici- adults over the age of 18 who used marijuana and pants who achieve and maintain abstinence during had concerns or were interested in obtaining infor- treatment. mation. These strategies highlighted the objective, In reviewing the above work, it appears that non-judgmental, and confidential approach of the some participants who sought treatment have been study. All announcements emphasized that the substantially aided in either quitting or cutting MCU was not a treatment program. Those who back. However, it is also apparent that the majority inquired were told that although this program did of those treated in the these studies reported above not offer counseling for persons who wanted to quit did not achieve their initial goal of durably ab- or reduce their use, it would likely be useful in staining from marijuana. Given the evidence of the helping an individual better assess their experi- drug’s dependence potential and adverse health ences with marijuana. consequences (Hall, Johnston, & Donnelly, 1999), The first MCU session involved a structured in- continuing development and testing of marijuana terview that included an assessment of the individ- dependence interventions is clearly warranted. ual’s use patterns, perceived benefits and adverse Support Groups. Marijuana Anonymous consequences associated with both continued use groups, a self-help fellowship based on the princi- and reductions or cessation of use, and self-efficacy ples and traditions of Alcoholics Anonymous, exist in accomplishing cessation. In the second session, in a number of states and internationally. In addi- feedback to the client from the initial assessment tion to in-person meetings, MA sessions are also was largely normative and risk-related in nature. held on-line. The organization’s web site address is: Utilizing motivational interviewing skills, the ther- www.marijuana-anonymous.org, and its toll-free apist elicited the client’s views concerning benefits telephone number is 800-766-7669. and costs associated with both his or her current User Characteristics Predictive of Treatment marijuana use pattern, as well as various pathways Success. Stephens, Wertz, and Roffman (1993) of change. When appropriate, the discussion turned reported predictors of successful outcomes in their to goal-setting for reduction or cessation of use and first marijuana treatment trial. Higher levels of the identification of useful behavior change strate- pretreatment marijuana use predicted higher use gies. levels following treatment. Indicators of lower so- Based on the finding that 64 percent of partici- cioeconomic status predicted more reports of prob- pants met diagnostic criteria for cannabis depen- lems associated with marijuana use post-treatment. dence and, of those who did not, 89.4 percent met Finally, individuals who prior to treatment indi- criteria for cannabis abuse (American Psychiatric cated greater self-efficacy for avoiding use had Association, 1994), it was evident that the more successful post-treatment outcomes. check-up modality offered a useful method for Reaching the Non-Treatment-Seeking reaching the non-treatment-seeking heavy mari- Heavy Marijuana Smoker. With funding from juana user. Upon joining the study, fewer than a NIDA (1997 through 2000), Stephens and Rof- third had resolved to quit or cut back on their use. fman are conducting a clinical trial (‘‘The Mari- They were using marijuana on more than 80 per- juana Check-Up’’) with 188 non-treatment-seek- cent of the days prior to the interventions and ing adult marijuana smokers who have been typically getting high two or more times per day. randomly assigned to a motivational enhancement The check-up modality may also show promise intervention (The Personal Feedback Session), a in affecting behavior change. While the study is still marijuana educational intervention (The Multime- ongoing, preliminary analyses of outcomes indi- dia Feedback Session), or a brief waiting period. cated that participants in the motivational en- This study is adapted from a brief intervention hancement condition (the personal feedback ses- (‘‘The Drinker’s Check-Up’’) in the alcoholism sion) were more likely to both reduce the amount of field (Miller & Sovereign, 1989). marijuana smoked per day and the number of days In conducting The Marijuana Check-Up, a vari- of use than were those in the educational or wait- ety of recruitment strategies were used to attract list control conditions. participants, including posters, radio and newspa- Marijuana Withdrawal. A mild syndrome of per ads, and outreach at various community events withdrawal from marijuana has been reported, 1188 TREATMENT: Marijuana, An Overview with symptoms that may include: restlessness, irri- tagonist, a compound that blocks anandamide ac- tability, mild agitation, insomnia, decreased appe- tion in the brain (Rinaldi-Carmona, Barth, tite, sleep EEG disturbance, anxiety, stomach pain, Heaulme, et al., 1994). Taken together, these dis- nausea, runny nose, sweating, and cramping coveries have made it possible to systematically (Budney, Novy, & Hughes, 1999; Crowley, Mac- study the effects of chronic exposure to marijuana. donald, Whitmore, et al., 1998; Haney, Ward, With greater understanding of the cannabinoid Comer, et al., 1999; Jones, Benowitz, & Bachman, neurochemical system’s physiology, the potential 1976). Commonly, these symptoms lessen within a for developing and testing pharmacological inter- week to 10 days. ventions for marijuana dependence is advanced. The Future of Marijuana Interventions. Currently underway or recently completed con- BIBLIOGRAPHY trolled trials testing various models of marijuana dependence treatment with adults and adolescents AMERICAN PSYCHIATRIC ASSOCIATION (1994). Diagnostic will undoubtedly contribute new information to and Statistical Manual of Mental Disorders (4th ed.). what is currently known. The ‘‘leading edge’’ of ANTHONY, J. C., & HELZER, J. E. (1991). Syndromes of such studies include counseling interventions in drug abuse and dependence. In L. N. ROBINS &D.A. which contingency management components, vari- REGIER (Eds.), Psychiatric Disorders in America (pp. ations in motivational enhancement strategies, 116–154). New York: Free Press. brief and extended cognitive-behavioral therapies, ANTHONY, J. C., WARNER, L. A., & KESSLER,R.C. treatments involving family members, and alterna- (1994). Comparative epidemiology of dependence on tive dosages and distributions of counseling epi- tobacco, alcohol, controlled substances, and inhal- sodes are being evaluated. ants: Basic findings from the National Comorbidity The treatment of marijuana dependence may Survey. Experimental and Clinical Psychopharmaco- also ultimately be informed by knowledge of hu- logy, 2, 244–268. man biology. As an example, there is some evidence BIEN, T. H., MILLER, W. R., & TONIGAN, S. (1993). Brief for the role of genetics in determining whether the interventions for alcohol problems: A review. Addic- marijuana user will become dependent. In a study tion, 88, 315–336. of more than 8,000 male twins, genes were shown BUDNEY, A. J., HIGGINS, S. T., RADONOVICH, K. J., ET AL. to influence whether a person finds the effects of (in press). Adding voucher-based incentives to marijuana use pleasant (Lyons, Toomey, Meyer, et coping-skills and motivational enhancement imal., 1997). Comparable findings were demon- proves outcomes during treatment for marijuana de- strated for females (Kendler & Prescott, 1998). pendence. Journal of Consulting and Clinical Psy- While factors in an individual’s social environment chology. clearly influence whether he or she ever tries mari- BUDNEY, A. J., NOVY, P. L., & HUGHES, J. R. (1999). juana, becoming a heavy user or abuser may be more determined by genetically transmitted indi- Marijuana withdrawal among adults seeking treat- vidual differences, perhaps involving the brain’s ment for marijuana dependence. Addiction, 94, reward system. Research in this area may eventu- 1311–1322. ally identify individual risk factors for marijuana CROWLEY, T. J., MACDONALD, M. J., WHITMORE, E. A., ET dependence that people can use in making deci- AL. (1998). Cannabis dependence, withdrawal, and sions about their own use of this drug. reinforcing effects among adolescents with conduct Finally, considerable evidence for a biological symptoms and substance use disorders. Drug and basis to marijuana dependence has accumulated Alcohol Dependence, 50, 27–37. since the identification of a specific cannabinoid DEVANE, W. A., DYSARZ, F. A., JOHNSON, M. R., ET AL. receptor in the brain (Devane, Dysarz, Johnson, et (1988). Determination and characterization of a can- al., 1988) and the discovery of anandamide, a com- nabinoid receptor in rat brain. Molecular Pharmacol- pound that binds to and activates the same receptor ogy, 34, 605–613. sites in the brain as delta-9-tetrahydrocannabinol DEVANE, W. A., HANUS, L., BREUER, A., ET AL. (1992). (THC), the active ingredient in marijuana. Isolation and structure of a brain constituent that (Devane, Hanus, Breuer, et al., 1992). Subse- binds to the cannabinoid receptor. Science, 258, quently, researchers discovered a cannabinoid an- 1946–1949. TREATMENT: Polydrug Abuse, An Overview 1189

DONALDSON, J. (Chair) (1998, November). Treatment of STEPHENS, R. S., ROFFMAN, R. A., & CURTIN, L. (In press) marijuana dependence: Recent advances in clinical Comparison of extended versus brief treatments for epidemiology and health services research. Sympo- marijuana use. Journal of Consulting and Clinical sium conducted at the annual meeting of the Ameri- Psychology. can Public Health Association, Washington, D.C. STEPHENS, R. S., ROFFMAN, R. A., & SIMPSON,E.E. HALL, W., JOHNSTON, L., & DONNELLY, N. (1999). Epi- (1994). Treating adult marijuana dependence: A test demiology of cannabis use and its consequences. In H. of the relapse prevention model. Journal of Consulting KALANT,W.A.CORRIGALL,W.HALL, ET AL. (Eds.), and Clinical Psychology, 62, 92–99. The Health Effects of Cannabis (pp. 71–125). STEPHENS, R. S., WERTZ, J. S., and ROFFMAN,R.A. Toronto: Addiction Research Foundation. (1993). Predictors of marijuana treatment outcomes: HANEY, M., WARD, A. S., COMER,S.D.,ET AL. (1999). The role of self-efficacy. Journal of Substance Abuse, Abstinence symptoms following smoked marijuana in 5, 341–354. humans. Psychopharmacology, 141, 395–404. SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES JONES, R. T., BENOWITZ,N.,&BACHMAN, J. (1976). Clin- ADMINISTRATION (SAMHSA). (1999). Summary Find- ical studies of tolerance and dependence. Annals of ings from the 1998 National Household Survey on the New York Academy of Sciences, 282, 221–239. Drug Abuse. Office of Applied Studies, August, 1999. KANDEL, D. C., & DAVIES, M. (1992). Progression to ROGER A. ROFFMAN regular marijuana involvement: Phenomenology and ROBERT S. STEPHENS risk factors for near daily use. In M. GLANTZ &R. PICKENS (Eds.), Vulnerability to Drug Abuse (pp. 211–253). Washington, D.C.: American Psychologi- Polydrug Abuse, An Overview Polydrug cal Association. abuse (also called multiple-drug abuse) refers to KENDLER, K. S., & PRESCOTT, C. A. (1998). Cannabis the recurring use of three or more categories of PSY- use, abuse, and dependence in a population-based CHOACTIVE substances. It is a pattern of substance sample of female twins. American Journal of Psychia- abuse that is most commonly associated with illegal try, 155, 1016. drug use and youth. Most polydrug users also LYONS, M. J., TOOMEY, R., MEYER, J. M., ET AL. (1997). smoke TOBACCO, but NICOTINE has only recently How do genes influence marijuana use? The role of begun to be recognized as a drug of abuse to be subjective effects. Addiction, 92, 409–417. addressed with polydrug users. MILLER, W. R. (1983). Motivational interviewing with While the term Polydrug User is usually reserved problem drinkers. Behavioural Psychotherapy, 11, for people with a rather varied and nonspecific 144–172. pattern of drug use, many drug users who have a MILLER, W. R., & ROLLNICK, S. (1991). Motivational In- preferred (a primary) drug of abuse are also poly- terviewing: Preparing People to Change Addictive Be- drug users. In fact, it is uncommon for users of any havior. New York: Guilford Press. illicit drug to restrict their substance use to only the MILLER, W. R., & SOVEREIGN, R. G. (1989). The check- one drug. For example, an individual may be a up: A model for early intervention in addictive behav- regular COCAINE user but also use ALCOHOL,TRAN- iors. In T. LOBERG,W.R.MILLER,P.E.NATHAN, ET QUILIZERS, and MARIJUANA. AL. (Eds.), Addictive Behaviors: Prevention and Early Intervention (pp. 87–101). Amsterdam: Sweta & WITHDRAWAL Zeitlinger. RINALDI-CARMONA, M., BARTH, F., HEAULME, M., ET AL. The intensity of withdrawal symptoms and their (1994). SR 141716A, a potent and selective antago- medical risk depends on the particular substances nist of the brain cannabinoid receptor. FEBS Lett., used and the degree to which dependence has de- 350, 240–244. veloped. Withdrawal is most often clinically signifi- STEPHENS, R. S., ROFFMAN, R. A., BURKE, R., ET AL. cant in those who have developed severe depen- (1998, November). The marijuana check-up. Paper dence on a primary drug of abuse; the medical risks presented at the annual conference of the Association of such withdrawal vary substantially with the type for Advancement of Behavior Therapy, Washington, of drug. For example, much greater risks exist for D.C. BARBITURATE than for HEROIN withdrawal. The re- 1190 TREATMENT: Polydrug Abuse, An Overview cent use of other drugs in addition to the primary The assessment process offers an excellent opportu- drug of abuse complicates the withdrawal process. nity to enhance the polydrug user’s motivation for In such cases, careful medical assessment is impor- change by providing feedback and support, as well tant in the planning of withdrawal management for as by helping the person to clarify goals and values. polydrug users. Polydrug users who typically dabble among the TREATMENT APPROACHES available drugs without developing severe dependence on any of them usually have no clinically Many different treatment approaches are avail- serious problems when they stop using drugs. They able, but they reflect differing conceptual or theo- may experience some discomfort, agitation, or retical perspectives on the origins of drug-use prob- sleeplessness but they do not normally require lems as well as on the best ways to treat them. Most medical treatment. Social stability and support of these approaches were not developed for the would be important, however, as the risk of relapse polydrug user but, instead, were adapted from could be high during this period of discomfort. other substance-abuse treatments. The approaches described may be presumed to be quite widely ASSESSMENT available except where restrictions are noted. Re- search evidence concerning their comparative ef- There are two main purposes of assessment: fectiveness for polydrug users is extremely limited. (1) to determine what specific treatment would be Approaches Based on the Disease Concept. most suited to the specific needs of the polydrug According to one variant of the disease concept, user; and (2) to determine baseline levels of func- alcoholism and drug addiction are incurable dis- tioning against which progress in treatment can be eases. Those affected are considered unable to con- measured. Assessment must address many areas of trol their use of the substance, because of an aller- functioning in addition to drug use. These include giclike, biological reaction. This approach has only the following: medical and psychiatric problems; one solution to the problem—to get the user to family and other social relationships; school or work abstain from any use of the drug. problems; leisure activities and skills; criminal ac- Twelve-Step Groups. The treatment approaches tivities and legal problems; and financial status. most commonly associated with the disease concept Drug use must be carefully assessed in the poly- are those based on ALCOHOLICS ANONYMOUS (AA), drug user, because of the variety of drugs used and which was started in 1935. The TWELVE-STEP ap- the need to evaluate the risks associated with the proach developed by AA has been adapted for ap- particular pattern of use. The usual procedure is to plication to other primary drugs of abuse, e.g., divide drug use into categories based on pharmaco- NARCOTICS ANONYMOUS (NA) and COCAINE logical similarities. These categories typically in- ANONYMOUS (CA). Like AA, these approaches rely clude: alcohol; marijuana; HALLUCINOGENS (e.g., exclusively on self-help peer-group procedures. LSD); heroin; other OPIOIDS (e.g., CODEINE); co- Members voluntarily embark on a lifetime journey caine; other STIMULANTS (e.g., AMPHETAMINES); of recovery, armed with a set of principles and the TRANQUILIZERS (e.g., BENZODIAZEPINES such as Valium) and other sedative hypnotics (e.g., barbi- support of peers who share a common problem and turates); and solvents (including glue). Because ac- a desire for change. The central features of these curate estimates of doses are very difficult to obtain approaches are the following: an acceptance of be- from polydrug users, their drug use is usually as- ing powerless over the drugs; a belief in a higher sessed as the number of times each drug has been power; a commitment to make restitution to those used within a specified time period. Other impor- who have been harmed; and personal responsibility tant factors to consider in assessing drug use are to maintain abstinence. Polydrug users may affili- risks related to HUMAN IMMUNODEFICIENCY VIRUS ate with any of such groups, depending on the (HIV) infection—especially injection drug use, and particular drugs most commonly used. They may, drugs used in combination. however, have some difficulty in identifying with A further consideration in assessment is the cli- the majority of group members as peers. Often a ent’s commitment to change. Polydrug users may buddy or two with the same problems and concerns be, at best, ambivalent about the need for change. become a special subgroup. TREATMENT: Polydrug Abuse, An Overview 1191

Chemical-Dependency Programs. Some treatment ing problem of drug abuse may be dealt with di- programs, most notably residential programs, have rectly within the framework of the family ap- adapted the twelve-step approach as the basis of proach. It may otherwise be treated as a symptom their treatment. Chemical-dependency (CD) proof the family’s dysfunction—where the expectation grams are the most prominent example. These pro- is that the drug use will disappear with resolution of grams are an extension of the four week MINNESOTA the more fundamental family problems. MODEL (for ALCOHOLISM) to a broader range of In family therapy, all or most of the family substances of abuse. Some have a particular focus members typically attend the treatment sessions. for young polydrug users. One-person family therapy is a variation on this The CDapproach usually involves a three- to six- practice, in which the treatment focuses on changes week structured and intensive residential-treatment to the family system via one member of that system. phase, which includes lectures and discussions This practice is, however, very limited in compari- about the harmful effects of drug use; group-ther- son with the more common approach of involving apy sessions that focus on breaking down denial and most or all the other family members. personal issues related to drug use; an orientation to Peer-Network Therapy. Peer-network therapy fo- the twelve-step approach; recreational and physical cuses on the peer or friendship social system. Poly- activity; and family counseling sessions. The resi- drug users are typically young and their drug use is dential phase is followed by an extended aftercare often a social activity. Much research evidence links program, typically involving attendance at AA, NA, all drug use to peer associations. This may be or CA meetings. Many CDprograms specialize in the caused by peer influence or because drug users seek treatment of polydrug users who also have coex- out other drug users. Either way, it is widely be- isting psychiatric problems. lieved that changes in peer associations are a neces- The number of CDprograms has grown rapidly sary step for polydrug users who would attempt to in the past decade, particularly in private hospitals. discontinue drug use. Because of their residential phase, these CDpro- Peer-network therapy involves systematically grams are among the most expensive form of treat- examining the relationship of drug use to associa- ment available to polydrug users. tion with particular peers. Strategies involve avoid- Systems Theory–Based Approaches. Sys- ing certain peers; strengthening peer relationships tems theory holds that individuals function within in which drug use is not a factor; reestablishing old a variety of social systems (e.g., the family and peer relationships that may have been ignored while groups) and that these systems act to influence drug use was occurring; using a buddy system to behavior and to resist changes that are not in the facilitate developing new peer relationships; and interest of the broader system. From this perspec- structuring leisure activities to help the client meet tive, drug use may be seen as serving some useful new friends who share similar attitudes and goals purpose within the ‘‘identified client’s’’ social sys- concerning drug use. Typically, changes in the peer tems. Attempts to change that drug-use behavior system are introduced via the identified client, but without ensuring that the system will support and peer-network therapy may also involve sessions maintain such a change may be doomed to failure. that include other members of the peer network. Family Therapy. Family therapy is the most com- Peer-network therapy is still a relatively novel mon application of systems theory to the treatment approach to the treatment of polydrug users, al- of polydrug users. This is because research has though many treatment programs are placing in- linked various forms of family dysfunction to the creased emphasis on changes to peer networks as development of drug-use problems. Also, many part of their overall treatment strategy. polydrug users are children and young adolescents Peer Counseling. Polydrug use is the most common and their drug use is a major family issue. pattern of substance abuse for many novice drug In family therapy, the family rather than the users. For such individuals, early intervention pro- polydrug user becomes the client. Treatment ad- grams based on peer counseling, and provided in dresses family-system issues, which include family school or neighborhood settings, may be appropri- roles, patterns of communication, and structural ate. Peer counseling capitalizes on the tendency for factors such as the alliances that may exist within adolescents to be most influenced by their peers. and among parts of the family system. The present- Peer counselors are selected on the basis of their 1192 TREATMENT: Polydrug Abuse, An Overview ability to act as good role models. They are trained cording to a random schedule that minimizes the to emphasize practical strategies to assist polydrug opportunity to plan drug use to escape detection. A users to change their lifestyles in ways that support variety of types of consequences can be used. For becoming drug free. They also act as facilitators or example, clients may avoid the loss of a job, regain group leaders in peer counseling groups, in which custody of children, or avoid breach of probation adolescents learn from each other. by consistently providing ‘‘clean’’ urines. While Social Learning Theory–Based Approaches. many treatment programs emphasize the conse- Social learning theory suggests that drug use is a quences of drug use, few do so in the very system- learned behavior and that it may be changed by the atic way required by contingency management. therapeutic application of principles of learning Cue Exposure. Cue-exposure techniques focus on theory. Treatments based on social learning theory the circumstances that precede or ‘‘cue’’ drug use. usually begin with a functional analysis of the drug Frequent repetition of patterns of drug taking may use. This involves a detailed analysis of the circum- result in certain cues becoming conditioned so that stances in which drug use occurs and the apparent the user experiences cravings for the drug in the benefits to the user. The basic assumption is that presence of these cues. For example, observing drug use serves useful purposes (functions) in the drug-use paraphernalia or being in a setting in life of the user and that understanding these func- which drugs have frequently been used in the past, tions of drug use is a critical step in planning treat- may cause the polydrug user to experience ment. cravings. These cues can be the cause of relapse. Coping Skills Training. One such treatment ap- Treatment involves repeatedly exposing the indi- proach is based on substituting alternative methods vidual to these cues in a controlled manner (e.g., of obtaining the same benefits that drug use pro- with a supportive person present) until the cue no vides. If the individual becomes more sociable and longer elicits the craving response. Conditioning is outgoing on drugs, social-skill training is provided; more apt to occur for a specific drug than across a if drug use reduces tension, stress-management variety of drugs. Hence cue exposure may be most techniques are offered. This approach is sometimes relevant for polydrug users with a pronounced pri- referred to as coping-skills training, because im- mary drug of abuse. proved coping in one or more life areas usually be- Approaches Aimed at Major Psychological comes the primary treatment goal. Coping-skills Change. These approaches assume that the cause training can address a variety of skill deficits from of drug use lies in the psychological makeup of the improved problem solving, to coping with depres- polydrug user. From this perspective, drug use is a sion, to increased assertiveness. The objective is to self-destructive or deviant act brought about by provide the polydrug user with alternative methods serious underlying psychological problems or the of coping with difficult life situations. adoption of anti-social values. Treatment is aimed Since the 1970s, this type of approach has beat correcting the underlying problem for which come the primary alternative to more traditional drug use is thought to be merely a symptom. approaches based on the disease concept or psycho- Psychotherapy. Psychotherapy is an intensive and therapy. extended counseling approach in which the thera- Contingency Management. Contingency manage- pist explores the past events in the client’s life with ment involves structuring unpleasant consequences the aim of uncovering emotionally upsetting events to occur when drugs are used. The assumption is or identifying themes or patterns of behavior that that these adverse consequences will compete with interfere with the effective social and psychological the benefits the user gets from the drug use, thereby functioning of the individual. The drug use itself reducing the likelihood that drug use will continue. would seldom be the focus of the treatment ses- Contingency management procedures are most ef- sions. Rather, the goal of psychotherapy would be fective when the occurrence of the drug use behav- psychological growth to change the personality of ior can be reliably determined and the prescribed the polydrug user. consequences reliably administered. Urine screen- Psychotherapy can be provided on a one-to-one ing is the most common means of monitoring or group basis. It is typically provided on an outpa- whether any drug use has occurred. Clients are tient basis but has also been provided within the typically required to provide urine specimens ac- framework of long-term residential programs for TREATMENT: Polydrug Abuse, An Overview 1193 young drug users. Psychotherapy can be a compar- at least contribute to, the substance-abuse prob- atively expensive form of treatment, because it re- lem. Most pharmacotherapy approaches are in- quires highly skilled therapists and typically takes tended to address the misuse of specific substances, longer to complete than other therapies. It may be which limit their application to polydrug users; most relevant when the polydrug user also has a however, many polydrug users have preferred psychiatric problem (e.g., depression). drugs of abuse for which a pharmacotherapy ap- Therapeutic Communities. THERAPEUTIC proach may be appropriate. In such instances, it COMMUNITIES (TC’s) are long-term residential pro- will usually be necessary to combine the phar- grams of twelve to twenty-four months duration. macotherapy treatment with some other approach There are several types of TC, all of which share a to ensure that treatment addresses all the individ- common belief that clients gain from living to- ual’s drugs of abuse. gether in a therapeutic environment for an ex- Methadone treatment is the best-known of the tended period of time. The most prominent TC drug-substitution approaches. Methadone substi- model is based on the Synanon program developed tutes for heroin (and other opioid drugs) prevent for heroin addicts in the late 1950s. Since that time, the onset of withdrawal symptoms in addicts. This many variations of this model have evolved and the serves to stabilize the user with regard to the desire target treatment population has been broadened to or need to continue heroin use until the addict de- include polydrug users. velops sufficient confidence and a strong enough The treatment approach is typically targeted to support system to become drug free. hard-core drug users who are judged to have seri- Other drugs used in treatment (e.g., NALTREX- ous personality deficits or chronic antisocial values. ONE) act on the brain to block or reduce the pleas- The problem is presumed to be the person, not the ant sensations associated with the use of particular drug or the individual’s social environment. The drugs. The assumption is that if the so-called bene- treatment is extremely intensive, often involving ficial effects of the drug are eliminated or reduced, harsh confrontation and emotionally charged en- it is less likely to be used. So-called anti-alcohol counters. The intent is to break through the protec- drugs (ANTABUSE and Temposil) take this notion tive shell that the polydrug user has developed—in one step further, by altering the metabolism of response to past deprivations and abuse—and to alcohol so that its effects become very unpleasant resocialize the individual to adopt new values and (the individual gets sick if alcohol is consumed patterns of behavior. Consistent with its self-help while the drug is in effect). For all these ap- origins, treatment within the TC is usually pro- proaches, strategies to ensure that the individual vided by recovered addicts. actually takes the prescribed drug are very impor- Psychobiological Approaches. Psychobio- tant since the polydrug user can easily obtain the logical approaches involve interventions which desired drug effects just by not taking the treat- have a biological (often neurological) mechanism ment drug. of action. Examples include treatments that involve Finally, some polydrug use reflects an attempt at the administration of a drug (pharmacotherapies) self-medication to cope with symptoms of un- and ACUPUNCTURE, although the latter has had treated psychiatric problems. The appropriate di- little application to the treatment of polydrug users. agnosis and treatment (with medication) of such These approaches are based on the assumption that problems may reduce the client’s need to self-medi- it is possible to change drug-use behavior by bio- cate. Examples of this form of pharmacotherapy logical methods even though the drug-use problem include medications for the treatment of anxiety, may not have biological origins. For example, a mood disorder, and psychotic disorders. drug may be used in treatment to eliminate the positive effects of an abused drug, thereby reducing THE IMPORTANCE OF MATCHING the likelihood that its use will continue. TREATMENT TO CLIENT NEEDS Pharmacotherapies. Drugs are used in the treatment of substance-abuse problems for a variety of This chapter has described a broad range of purposes. These include substituting for the drug treatment approaches available to the polydrug effect; blocking or changing the drug effect; or user. In practice, treatment programs often com- treating a condition that is believed to underlie, or bine elements of the various approaches described. 1194 TREATMENT: Polydrug Abuse, Pharmacotherapy

None of the approaches can claim general superior- senting with dependencies upon two or more such ity over any other. Any one of them may be the substances. The DIAGNOSTIC AND STATISTICAL most appropriate treatment choice for a particular MANUAL of the American Psychiatric Association individual under certain circumstances. It is impor- (DSM-IV) and the INTERNATIONAL CLASSIFICATION tant to assess the needs and wishes of the polydrug OF DISEASES of the World Health Organization user carefully before selecting the treatment that (ICD-10) define a condition called ‘‘polydrug de- seems most likely to be most helpful. pendence’’ or ‘‘multiple drug dependence,’’ in which there is dependence on three or more psy- (SEE ALSO: Addiction: Concepts and Definitions; choactive substances at one time. Polydrug depen- Adolescents and Drug Use; Causes of Substance dence is particularly common among adolescents Abuse; Comorbidity and Vulnerability; Contin- and young adults. However, if one includes NIC- gency Contracts; Disease Concept of Alcoholism OTINE and CAFFEINE dependence, over half of pa- and Drug Abuse; Methadone Maintenance Pro- tients with psychoactive-substance dependence are grams; Prevention; Treatment Types) polydrug-dependent. The use of specific, preferred combinations of BIBLIOGRAPHY drugs is typically seen in polydrug users. OPIOIDS and COCAINE are often used together, as are ALCO- BESCHNER, G. M., & A. S. FRIEDMAN (1985). Treatment HOL and cocaine or nicotine and alcohol. Alcohol, of adolescent drug abusers. International Journal of BENZODIAZEPINES, and cocaine are often used to- the Addictions, 20 (6&7), 971–993. gether by opiate users, especially METHADONE DELEON,G.,&D.DEITCH (1985). Treatment of the ado- users. Illicit-drug users often show nicotine and lescent substance abuser in a therapeutic community. caffeine dependence. Some individuals will use In A. S. Friedman & G. M. Beschner (Eds.), Treat- whatever psychoactive substances are available. ment services for adolescent substance abusers. Rock- One useful distinction is the difference between si- ville, Maryland: National Institute on Drug Abuse. multaneous and concurrent polydrug use. In simul- HUBBARD, Robert L., ET AL. (1989). Drug abuse treat- taneous polydrug use, the drugs are used together ment: A national study of effectiveness. Chapel Hill; at the same time for a combined effect, such as University of North Carolina Press. heroin and cocaine mixed and injected as a INSTITUTE OF MEDICINE. (1990). Treating drug problems, ‘‘speedball.’’ In concurrent polydrug use, the vari- vol. 1. Washington, D.C.: National Academy Press. ous drugs are used regularly but not necessarily KAUFMAN, E. (1985). Family systems and family therapy together. An example is a heroin user who uses of substance abuse: An overview of two decades of benzodiazepines and alcohol to get another kind of research and clinical experience. International Jour- high. In other cases, the polydrug abuser may self- nal of the Addictions, 20 (6&7), 897–916. medicate with one drug to offset the side effects of ONKEN, L. S., & J. D. BLAINE (1990). Psychotherapy and another. Cocaine abusers often take diazepam counseling in the treatment of drug abuse. Rockville, (Valium) to relieve the irritability that follows co- Maryland: National Institute on Drug Abuse. caine binges. Heroin addicts sometimes take benzo- WILKINSON, D. A., & Garth W. MARTIN (1991). Interven- diazepines to relieve the anxiety that characterizes tion methods for youth with problems of substance the early stages of opioid withdrawal. A more re- abuse. In Helen M. Annis & Christine Susan Davis cent development is the abuse of antidepressant (Eds.). Youth and drugs: Drug use by adolescents: medications among heroin users. The tricyclics ap- Identification, assessment and intervention. Toronto: pear to be abused more frequently than either the Addiction Research Foundation SSRIs or the MAO inhibitors. GARTH MARTIN TREATMENT The treatment of the polydrug user presents a Polydrug Abuse, Pharmacotherapy particular challenge to the clinician. The simulta- Although many individuals present with abuse or neous and concurrent use of multiple drugs may dependence upon a single PSYCHOACTIVE SUB- increase the level of dependence, increase drug tox- STANCE, increasing numbers of drug users are pre- icities, worsen medical and psychiatric TREATMENT: Polydrug Abuse, Pharmacotherapy 1195 comorbidities due to the drugs, and intensify with- occurs, as well as management of medical and psy- drawal signs and symptoms upon cessation of drug chiatric problems. Detoxification is the removal of use. The basic principles of treatment of polydrug the drug in a fashion that minimizes signs and use are similar to those for the treatment of any symptoms of withdrawal. It can be pharmacologi- single psychoactive-substance dependence. Pa- cal or drug free. Pharmacological methods for de- tients require a complete medical and psychiatric toxification include (1) a slow decrease in the dose assessment, treatment of active problems, detoxifi- of the drug or of a cross-tolerant agent (e.g., metha- cation, then rehabilitation with attempts to reduce done for heroin withdrawal, diazepam for alcohol subsequent use of the drugs. One of the complica- withdrawal, NICOTINE GUM for smoking cessation) tions of treating polydrug users is that the patient’s and (2) stopping the drug and using an alternative history may be unreliable— many cannot remem- agent to suppress signs and symptoms of with- ber what they have used and others do not know drawal (e.g., CLONIDINE for opioid withdrawal, the identity of drugs they have purchased on the atenolol for alcohol withdrawal). For many drugs, street. pharmacologically assisted detoxification is not In providing treatment for the polysubstance necessary. Simple alcohol withdrawal can be user, there are two options: (1) sequential treat- treated with supportive care. However, the pres- ment for the dependencies, with initial treatment of ence of polysubstance dependence usually in- the major dependency or the dependency with creases the need for pharmacological agents to as- greater morbidity; or (2) simultaneous treatment of sist in withdrawal. all dependencies. Unfortunately, few objective data There are few controlled studies on the clinical exist as to which type of treatment is optimal for course and optimal therapies for detoxification which patients. Most clinicians rely on their own from multiple psychoactive substances. Patients experience, the capabilities of the treatment setting, can be detoxified from all psychoactive substances and the wishes of the patient. One rule of thumb together, or maintained on one or more drugs while that has been suggested for complex detoxifications being detoxified from others. When the drugs used is to focus initially on the CNS depressant drug(s) are all part of the same class (e.g., alcohol and and not be overly concerned with the opioid com- sedatives; methadone, CODEINE, and heroin), a ponent. The patient can be stabilized with regard to complete detoxification is more common. When the the opioid with methadone, and given phenobarbi- drugs used are from different classes, partial or tal to prevent the potentially life-threatening symp- sequential detoxification usually occurs. An exam- toms of sedative withdrawal. ple of the latter situation is an opioid, cocaine, The treatment of polysubstance dependence of- alcohol, and nicotine user who is detoxified from ten involves more than one type of treatment mo- alcohol and cocaine, but maintained on methadone dality. A common example is an alcohol-depen- and allowed to continue tobacco use. Sometimes a dent, opioid-dependent, cigarette smoker who is partial detoxification is indicated because of the receiving METHADONE MAINTENANCE for opioid de- need for continued psychotropic medication for pendence, abstinence-oriented treatment for alco- medical or psychiatric illnesses, such as continued holism, and no specific treatment for nicotine de- opioids for chronic pain or benzodiazepines for pendence. The different treatment philosophies— anxiety. methadone substitution, abstinence, and no treat- Given the cross-tolerance of most SEDATIVE- ment—necessarily conflict. In such cases, good HYPNOTICS with ethanol, methods that are effective communication and flexibility among the various for the detoxification from alcohol or sedatives treatment providers and with the patient are im- alone are usually effective for the combinations of portant to ensure optimal, coordinated treatment. alcohol and sedatives. Loading techniques, with long-acting benzodiazepines, such as diazepam or CHLORDIAZEPOXIDE, or with BARBITURATES, such DETOXIFICATION as PHENOBARBITAL, are well documented as effec- During the initial treatment of polysubstance tive. The advantages of these methods include abuse and dependence, the primary goals include matching the medication used for withdrawal to cessation of substance use and the establishment of the individual patient’s tolerance and the avoid- a substance-free state. If necessary, detoxification ance of overmedication. The anticonvulsant car- 1196 TREATMENT: Polydrug Abuse, Pharmacotherapy bamazepine (Tegretol) has been shown to be effec- ‘‘speedball’’ self-administration are consistent with tive for the treatment of combined alcohol and the findings of clinical trials of buprenorphine in sedative withdrawal. polydrug abusers. Other research suggests that Although the mechanisms of action of various buprenorphine is effective in patients dependent on drugs differ, there are common neurological sub- both cocaine and heroin because it improves re- strates of certain behavioral effects and of with- gional cerebral blood flow. Desipramine has been drawal signs and symptoms. The autonomic hyper- reported as being effective in reducing cocaine use activity and some of the CNS excitation common to in methadone patients. Disulfiram, which is effica- several withdrawal syndromes are mediated by the cious in the treatment of alcoholism, may also re- locus ceruleus of the brain. Medications such as duce cocaine use in individuals using both alcohol alpha-2 antagonists (clonidine) and benzodiaze- and cocaine. pines, which inhibit locus ceruleus activity, have Newer pharmacological agents that are being been shown to attenuate the symptoms of nicotine investigated for possible use in long-term treatment withdrawal. However, clonidine will not block the of polydrug abuse include a medication mixture of seizures that result from alcohol or sedative with- flupenthixol, a dopamine antagonist, and drawal. quadazocine, an opioid antagonist. The mixture targets combined stimulant/opioid abuse. A combi- LONG-TERM TREATMENT nation of these two drugs appears to be more effec- In the long-term phase of treatment, the patient tive in treating combined abuse of heroin and co- undergoes rehabilitation and reestablishment of a caine than either antagonist alone. Another agent lifestyle free of drug dependency. Pharmacological that may have therapeutic potential is gamma-hy- treatment is sometimes used to assist rehabilitation. droxybutyric acid, a compound that affects the Pharmacotherapies may reduce drug craving, de- brain’s dopaminergic systems. It may also be a neu- crease protracted withdrawal symptoms, or de- rotransmitter. Gamma-hydroxybutyric acid, first crease positive reinforcing effects of the drugs. used as an anesthetic, emerged as a drug of abuse Types of pharmacological therapies used in long- around 1990. It is still used by bodybuilders, term treatment and rehabilitation include partygoers at ‘‘rave’’ dances, and polydrug abusers. (1) maintenance (e.g., methadone maintenance for As of 2000, preliminary evidence supports its use in the treatment of opiate dependence); (2) blockade the treatment of alcohol and opiate dependence. (e.g., NALTREXONE treatment for opioid dependence); (3) aversive therapy (e.g., DISULFIRAM for (SEE ALSO: Comorbidity and Vulnerability; Treat- alcoholism, possibly naltrexone for alcoholism); ment-Treatment Types) and (4) psychotropic drug treatment of coexisting psychiatric disorders, such as lithium for bipolar BIBLIOGRAPHY alcoholics, or methylphenidate for cocaine-dependent patients with ATTENTION DEFICIT DISORDER. BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck The use of pharmacological agents as adjuncts Manual of Diagnosis and Therapy, 17th ed. in the treatment of polysubstance dependence is an Whitehouse Station, NJ: Merck Research Laborato- area of active investigation. One medication that ries. may prove useful in the treatment of combined DARKE, S., & ROSS, J. (2000). The use of antidepressants cocaine and opioid dependence is buprenorphine among injecting drug users in Sydney, Australia. Ad- (Buprenex). This partial mu agonist, used as a diction, 95(3), 407–417. surgical analgesic, has shown efficacy as a substi- GALLOWAY, G. P., FREDERICK-OSBORNE, S. L., SEYMOUR, tute in the long-term treatment of opioid depen- R., CONTINI, S. E., & SMITH, D. E. (2000). Abuse and dence. Compared with methadone, buprenorphine therapeutic potential of gamma-hydroxybutyric acid. may produce less dependence and fewer with- Alcohol, 20(3), 263–269. drawal symptoms upon cessation. Buprenorphine GLASSMAN, A. H., ET AL. (1988). Heavy smokers, smok- treatment also may reduce cocaine use in some ing cessation and clonidine. Results of a double-blind, individuals dependent on both opioids and cocaine. randomized trial. Journal of the American Medical Animal studies of the effects of buprenorphine on Association, 259, 2863–2866. TREATMENT: Tobacco, An Overview 1197

GRIFFITHS, R. R., & WEERTS, E. M. (1997). Benzodiaze- the treatment of opioid dependence. Annual Review of pine self-administration in humans and laboratory Pharmacology and Toxicology, 20, 463–474. animals-implications for problems of long-term use SELLERS, E. M., ET AL. (1983). Diazepam loading: Sim- and abuse.Psychopharmacology (Berlin), 134(1), 1– plified treatment for alcohol withdrawal. Clinical 37. Pharmacology and Therapy, 6, 822. HARDMAN,J.G.,&LIMBIRD, L. E. (Eds.) (1996). Good- SENAY, E. (1985). Methadone maintenance treatment. man and Gilman’s the pharmacological basis of ther- International Journal of Addictions, 20, 803–821. apeutics, 9th ed. New York: McGraw-Hill. ROBERT M. SWIFT LEVIN, J. M., et al. (1995). Improved regional cerebral REVISEDBY REBECCA J. FREY blood flow in chronic cocaine polydrug users treated with buprenorphine. Journal of Nuclear Medicine, 36(7), 1211–1215. Tobacco, An Overview Ever since tobacco LICHTIGFELD, F. J., & GILLMAN, M. A. (1991). Combina- tion therapy with carbamazepine/benzodiazepine for use became popular, some users have been trying to polydrug analgesic/depressant withdrawal. Journal of quit. Sometimes they sought treatment because the Substance Abuse Treatment, 8(4), 293–295. tobacco was too expensive, because companions complained about the tobacco use, because they LISKOW, B. I., & GOODWIN, D. W. (1987). Pharmacologi- cal treatment of alcohol intoxification, withdrawal did not like the smoke in the air, or, in the case of and dependence. Journal of Studies on Alcohol, SMOKELESS TOBACCO (chewing tobacco or spitting 48(4), 356–370. snuff), because they did not like the tobacco juice LITTEN,R.Z.,&ALLEN, J. P. (1991). Phar- on the floor. Sometimes treatment was sought out macotherapies for alcoholism: Promising agents and of concern for health problems. clinical issues. Alcohol Clinical Experimentation and Cigarette smoking is the most common form of Research, 15(4), 620–633. tobacco use, and smoking is one of the nation’s MALCOLM, R., BALLENGER, J. C., STURGIS, E. T., & AN- most critical public health problems. Tobacco use TON, R. (1989). Double blind controlled trial compar- causes more than 430,000 deaths each year in the ing carbamazepine to oxazepam treatment of alcohol United States and is the leading preventable cause withdrawal. American Journal of Psychiatry, 146(5), of death. Most adults in the United States have 617–621. either smoked cigarettes or used some other to- MARTIN,C.S.,ARRIA,A.M.,MEZZICH,A.C.,& bacco product. In 1997, 71 percent of the popula- BUKSTEIN, O. G. (1993). Patterns of polydrug use in tion aged twelve or older had tried cigarettes at adolescent alcohol abusers. American Journal of Drug some time in their lives. This article focuses on the and Alcohol Abuse, 19(4), 511–521. treatment of cigarette smoking but will include a MELLO,N.K.,&NEGUS, S. S. (1999). Effects of brief discussion of the treatment of smokeless to- flupenthixol and quadazocine on self-administration bacco use, for which many of the same principles of speedball combinations of cocaine and heroin by apply. rhesus monkeys.Neuropsychopharmacology, 21(4), According to the Surgeon General’s report on 575–588. reduction of tobacco, existing types of smoking in- MELLO,N.K.,&NEGUS, S. S. (1998). The effects of tervention can be used to reduce smoking. Re- buprenorphine on self-administration of cocaine and searchers believe that widespread dissemination of heroin ‘‘speedball’’ combinations and heroin alone by the approaches and methods shown to be effective, rhesus monkeys.Journal of Pharmacology and Exper- especially in combination, would substantially re- imental Therapeutics, 285, (2) 444–456. duce the number of young people who will become MEYER, R. E. (1992). New pharmacotherapies for co- addicted to tobacco, increase the success rate of caine dependence . . . revisited. ARCHIVES OF GENERAL young people and adults trying to quit using to- PSYCHIATRY, 49 (11), 900–904. bacco, decrease the level of exposure of nonsmokers PATTERSON, J. F. (1990). Withdrawal from alprazolam to environmental tobacco smoke, reduce the dis- using clonazepam: Clinical observations. Journal of parities related to tobacco use and its health effects Clinical Psychiatry, 51 (5, supp.), 47–49. among different population groups, and decrease RESNICK, R. B., SCHUYTEN-RESNICK, E., & WASHTON, the future health burden of tobacco-related disease A. M. (1980). Assessment of narcotic antagonists in and death in this country. 1198 TREATMENT: Tobacco, An Overview

There are a number of different methods used in tion to or dependence on nicotine. In the 1950s and the treatment of nicotine addiction. Behavioral 1960s, many experts believed that smoking was counseling and nicotine replacement therapy have ‘‘just a bad habit.’’ Experts at that time failed to proven the most effective forms of intervention for appreciate that tobacco use was a form of drug use; nicotine addiction, particularly when they are com- instead, they saw smoking as the kind of habit that bined. Non-nicotine medications, such as antide- could be broken by taking certain behavioral steps. pressants, anxiolytics, and nicotine antagonists, are This attitude was the origin of the so-called behav- among the medications also used in treatment, ioral techniques for stopping smoking. though their efficacy is still under investigation. In the early part of the twentieth century, self- help movements were very popular and were di- TRENDS IN SMOKINGCESSATION rected against alcohol and other drug problems. Such efforts at behavioral changes have a long his- Although the prevalence of smoking among the tory in society. Perhaps because they are so com- American public decreased in the late 1900s, the monplace, people tend not to seek professional help current number of smokers is still substantial. In for dealing with minor behavioral problems. As a the late 1990s, about one-quarter of adult Ameri- result, it should not be surprising that over the cans, or about 48 million people, smoked. Most of years much of the ‘‘treatment’’ for cigarette smok- these people wanted to quit but were unable to do ing has been self-administered. However, research- so because they found it too difficult. According to ers find that self-help treatments have not generally some figures from the late 1990s, only an estimated been proven effective for most people. In one study 2.5 percent of all smokers successfully quit each of 5,000 smokers, only 4.3 percent of individuals year. who had quit on their own remained abstinent for one year after they attempted to quit. Self-help EFFECTS OF SMOKINGCESSATION treatments, combined with such intensive treat- There are a number of physiological effects that ment as behavioral counseling, nicotine replace- take place in the human body after cessation of ment, or the combination of the two, is likely to be smoking. About twenty minutes after cessation, the more effective. blood pressure and pulse rate return to normal, and No single treatment stands out as being the sin- the body temperature increases to normal. About 8 gle best way for all smokers. In general, however, hours later, the carbon monoxide level in the blood researchers have found that nicotine replacement drops to normal, and after 1 day, an individual’s therapy combined with behavioral counseling has chance of a heart attack decreases. After two days, shown the best results in the treatment of nicotine nerve endings start to regenerate, and the ability to addiction. smell and taste is improves. After two weeks, an individual’s circulation improves and the function- GROUP VERSUS ality of the lungs increase by a maximum of 30 INDIVIDUAL THERAPIES percent. After a year of smoking abstinence, the risk of coronary heart disease is reduced to half that Much of the instruction and support that is part of a smoker, and after five years of cessation, the of smoking treatment can be done individually— risk of death by lung cancer is cut in half. After one-on-one—with clients or can be delivered to a fifteen years, the risk of coronary heart disease is group of clients. Group programs have been used to equal to that of a nonsmoker. provide hypnotism, educational therapies, behavioral therapies, and combined therapies. There is no clear scientific evidence indicating which deliv- RESEARCH ON CESSATION OF ery system is best, but it is clear that group pro- TOBACCO USE grams can be less expensive than individual pro- Although the scientific study of smoking treat- grams and that some clients have strong personal ments dates from the mid-1900s, ‘‘nonscientific’’ preferences for how they wish to receive treatment: and ‘‘scientific’’ treatments often overlap. Until the Some enjoy the group support and like to share 1980s, there were still many observers who their experiences in a group; others find such in- doubted that tobacco use was based on an addic- volvement with groups unpleasant or embar- TREATMENT: Tobacco, An Overview 1199 rassing. As for the efficacy of such therapies, re- support smoking cessation. U.S. government agen- searchers have found that the more time counselors cies concerned with smoking and smoking-related spend with smokers in a treatment session, the disease have also developed and promoted materi- higher the likelihood of cessation. Longer duration als and procedures to foster smoking cessation. of treatment in weeks and the total number of The voluntary agencies have supported smoking treatment sessions is also associated with improved cessation efforts in the workplace, by providing odds of smoking cessation. smoking-treatment services and by promoting smoking bans in the workplace. EMPLOYEE ASSIS- PHYSICIAN-BASED TREATMENTS TANCE PROGRAMS (EAPs) increasingly offer help to smokers who are trying to quit. In addition to Physicians interested in preventive medicine workplaces, many public places, such as restau- make special efforts to encourage and support rants and other public buildings, now prohibit smoking cessation in their patients. In 1964, only smoking on their premises. Just as social pressures about 15 percent of current smokers reported that encouraged many smokers to start the habit, social a physician had advised them to quit smoking. By pressures might encourage them to stop. Once it 1987, about 50 percent of current smokers had was fashionable to be a cigarette smoker; now it is received such advice. Sometimes just the advice of becoming fashionable to stop smoking. a physician to quit and the setting of a quitting date can lead to successful smoking cessation. Physi- cians can also be helpful by referring patients to NICOTINE-REPLACEMENT smoking treatment programs. Specialists who deal THERAPIES with patients already suffering from a smoking- Nicotine-replacement therapies can help reduce related disease can be in a good position to help the nicotine withdrawal symptoms after smoking those who are well motivated to quit, but cardiac or cessation. Replacement therapies help individuals lung patients often fail to stop smoking. Being diag- deal with their smoking gradually by separating the nosed with a smoking-related disease is no guaran- behavioral and pharmacological components of tee that the patient will quit smoking. smoking. While physical symptoms of nicotine The Importance of ‘‘Minimal’’ Interventions. withdrawal are reduced, the individual can focus In medical settings, there has been research on the on dealing with the behavioral challenges of value of interventions (e.g., brief advice, pam- stopping. The most commonly used nicotine-re- phlets) that take only a few minutes of the physi- placement therapies are a gum that releases nic- cian’s time. Although the effects of these interven- otine as it is chewed and a patch that slowly re- tions are usually small, they are generally viewed as leases nicotine into the body through the skin. worthwhile because they can reach so many These therapies are available over-the-counter. smokers. Transdermal nicotine patches appear to be preferred by individuals over nicotine gum. They seem SMOKINGCESSATION EFFORTS to have the fewest side effects and are associated BY AGENCIES with the greatest long-term abstinence rates. Many diseases caused by smoking—cancer, Nicotine nasal sprays and nicotine vapor inhal- heart disease, lung disease—have agencies con- ers that deliver nicotine through the respiratory cerned with furthering research, dissemination of system are less common forms of nicotine-replace- public health information, and treatment of the ment therapy. They became available in the United disease. The Cancer Society, the Lung Association, States in 1996 and 1998, respectively. There have and the Heart Foundation are voluntary, charitable been reports of eye, nose, and throat irritation with organizations. Each has developed materials and the nasal sprays, but individuals have been known programs to promote smoking cessation. The mea- to build a tolerance to these effects. sured treatment effects of simple stop-smoking Nicotine-replacement therapy is considered an pamphlets are small, but since they can reach many effective treatment for smoking cessation, although smokers at very low cost, they should be viewed as the efficacy of the different methods varies when beneficial elements of the public-health efforts to used alone. In addition, a number of negative side 1200 TREATMENT: Tobacco, An Overview effects could potentially interfere with a patient’s Contingency contracting involves, for exam- success with the therapy. ple, the preparation of detailed contracts that spell out punishments that will follow OTHER DRUGTHERAPIES from the return to smoking (e.g., if the patient relapses, he or she will give $100 For someone who has tried repeatedly and yet to someone he or she dislikes). failed to stop smoking for good, a medicine that Aversive conditioning procedures (e.g., rapid could take away the desire to smoke would be wel- smoking, satiation) cause cigarette smok- come. A number of non-nicotine medications have ing to be associated strongly with the been developed to help aid smokers in the cessation acute unpleasant effects (such as dizzi- process. Nicotine antagonists help cut down on nic- ness and nausea) of smoking very heavily. otine withdrawal symptoms—including irritability and anxiety—or mimic the effects achieved by Relapse Prevention and the Maintenance of smoking and thus may help decrease an individ- Abstinence. RELAPSE PREVENTION programs ual’s desire for a cigarette. Such antagonists in- have been developed to reduce the problem of re- clude antidepressants, anxiolytics, and stimulants lapse or return to smoking. Many of the same be- or anorectics. Other medications make smoking havioral techniques used in multimodal programs distasteful to the user. Studies on the efficacy of are applied to the task of helping prevent relapse such non-nicotine drug therapies continue. and helping prevent the occasional slip back to smoking from becoming a permanent return. HYPNOSIS Smoker’s Anonymous Programs. Smokers have sometimes organized this type of program to HYPNOSIS is worth special mention because of its support smoking cessation. The program allows popularity as a smoking therapy. Careful evalua- smokers to support each other and teach each other tions of hypnotherapies show small or no treatment techniques that will help them to stop smoking and effects. One of the problems in studying to keep from returning to smoking. These programs hypnotherapies is that the actual hypnotic proce- have not generally become popular. This is in con- dures involved are not standardized. The kind of trast to the great popularity of ALCOHOLICS ANONY- procedures used and suggestions made to the hyp- MOUS (AA) groups. notized patient (e.g., ‘‘You will not want a cigarette’’ vs. ‘‘The thought of a cigarette will make you RELATION TO TREATMENT OF feel sick’’) differ from therapist to therapist. It is OTHER DRUGPROBLEMS important to deal with reputable therapists who charge reasonable fees for their services. Heavy smoking is strongly linked to heavy alcohol and other drug use. Smoking is often found in MULTIMODAL THERAPIES those with ALCOHOL and other drug problems. Those smokers who fail to stop smoking may have A wide range of behavioral therapies have been serious alcohol or other drug problems that require tested, and no single method stands out as particu- treatment before the smoking problem can be re- larly effective. Multimodal approaches have be- solved. come widely used, in hopes that something loaded into the shotgun will hit its mark. Currently, there ON SELECTINGA WAY TO is no reliable way to judge beforehand which STOP SMOKING smoker will be most helped by a particular technique (the exception being that heavier, more de- Smokers should be advised to take a long view of pendent smokers are consistently more likely to their efforts to stop smoking, understanding that if benefit from nicotine replacement). The mul- one method does not help them, they should try timodal, something-for-everyone approach is rea- another, and another, until they have stopped sonable. There is not room in this article to discuss smoking. Any one attempt to stop smoking can in detail the variety of behavioral therapies that meet with poor success. With repeated attempts, have been used, but they have in common the use of the smoker may encounter some success. Also, re- basic psychological principles of learning. peated attempts give the smoker experience with TREATMENT: Tobacco, Pharmacotherapy 1201

assorted treatment techniques, so that the individ- BIBLIOGRAPHY ual begins to learn for what helps and what does CINCIRIPINI, P. M., MCCLURE, J. B. (1998). Smoking Ces- not help. Finally, there may be a kind of ‘‘no more sation: Recent Developments in Behavioral and Phar- nice guy’’ effect, so that the smoker gets fed up with macologic Interventions, Oncology, 12. failing to quit smoking. JOHNSTON, L. D., O’MALLEY, P. M., & BACHMAN,J.G. It is also important to realize that no two pro- (2000). Monitoring the Future national survey results grams are delivered in exactly the same way. The on drug use, 1975–1999 Volume I: Secondary school individual characteristics of a therapist and the cli- students (NIH Publication No. 00-4802). Rockville, ent’s rapport with that therapist can contribute to a MD: National Institute on Drug Abuse. therapy’s success. The person who wants help to SCHWARTZ, J. L. (1987). Review and evaluation of smok- stop smoking should investigate available commu- ing cessation methods: The United States and Can- nity resources; the library is good place to start. If ada, 1978–1985. Washington, DC: Division of Can- cer Prevention and Control, National Cancer the first attempt fails, additional attempts should Institute. be planned. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. (1990). The health benefits of smoking cessation: A A NOTE ON SMOKELESS TOBACCO report of the surgeon-general. Washington, DC: U.S. Government Printing Office. To the extent that chewing tobacco and dipping U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. snuff can cause nicotine to be delivered to the brain (1989). Reducing the health consequences of smok- in sufficient doses, they present a similar risk of ing: A report of the surgeon-general. Washington, DC: nicotine dependence in the regular user. These U.S. Government Printing Office. products may prove more difficult to treat than U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. cigarette use, because they are sometimes viewed as (2000). Reducing tobacco use: A report of the sur- less risky alternatives to cigarettes. One study geon-general. Washington, DC: U.S. Government quoted in a Surgeon General’s report on smoking Printing Office. reported that 77 percent of youth thought that U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. (1988). The health consequences of smoking: Nic- cigarette smoking was very harmful, but only 40 otine addiction: A report of the surgeon-general. percent rated smokeless tobacco as very harmful. Washington, DC: U.S. Government Printing Office. Once the ‘‘negative publicity’’ on smokeless to- U.S. DEPARTMENT OF HEALTH,EDUCATION AND WELFARE. bacco use reaches a level close to the bad press on (1979). Smoking and health: A report of the surgeon- smoking, there should be a growing demand for general. Washington, DC: U.S. Government Printing using the smoking therapies as treatments for the Office. use of smokeless tobacco. LYNN T. KOZLOWSKI In addition to the problems associated with nic- REVISEDBY PATRICIA OHLENROTH otine addiction, smokeless tobacco can cause bleeding gums and sores of the mouth that never heal. It is also associated with cancer. Smokeless tobacco Tobacco, Pharmacotherapy Although also stains the teeth a dark yellow-brown color, tobacco use causes a powerful addiction, people gives the user bad-smelling breath, and can cause who want to stop using it can be helped, and at far dizziness, hiccups, and vomiting in the individual. less expense than treatment of tobacco-caused dis- A further risk associated with smokeless tobacco is eases—which will kill approximately one in two that youth who use it are more likely to try smoking smokers who do not quit. The effort to find phar- than those who do not use it. macological agents that would help tobacco users quit is not a new development. In the late 1890s and early 1900s, a number of potent medicines (SEE ALSO: Addictions: Concepts and Definitions; were advertised as being useful for reducing to- Nicotine Delivery Systems for Smoking Cessation; bacco craving and helping break the habit. Such Tobacco: Treatment Types) advertising was possible because at the time there 1202 TREATMENT: Tobacco, Pharmacotherapy were no regulations requiring a seller to demon- smoker, because smokers may change their behav- strate that the product was effective. None of the ior to compensate for differences in cigarette products offered to the public between the early brands. For example, they may take additional 1900s and the late 1970s were demonstrably bet- puffs on low-nicotine brands. ter than placebos in helping smokers quit. Effec- Cigarette smoking produces rapid and large tive pharmacological approaches to treating nic- physiological changes, but, to a lesser extent, otine addiction, including transdermal patches smokeless tobacco produces similar effects. Nic- that deliver nicotine through the skin, and resin otine gum and patch treatments have the advan- complexes (gum) that release nicotine when tages of much slower nicotine delivery, and they chewed, were among the important medical advances of the 1980s and 1990s. To understand produce less severe physiological changes. This how pharmacotherapy works, it is necessary to un- slower delivery rate may be less pleasurable to the derstand the role of NICOTINE in the addiction to tobacco user, but the user is less likely to have tobacco. difficulty giving up the gum or the patch after treat- Nicotine is a naturally occurring alkaloid pres- ment. ent in the tobacco leaf. It is a small lipid and water- Tobacco-caused cancer may be considered a soluble molecule, rapidly absorbed through the side effect of nicotine dependence in much the same skin and mucosal lining of the mouth and nose or way that ACQUIRED IMMUNODEFICIENCY SYNDROME by inhalation in the lungs. In the lungs, nicotine is (AIDS) may occur as a side effect of heroin depen- rapidly extracted from tobacco smoke within a few dence. In both cases, the exposure to the disease- seconds because of the massive area for gas ex- causing toxins or to HIV occurs repeatedly and change in the alveoli; it is passed into the pulmo- often frequently because individuals are dependent nary veins, and pumped through the left ventricle on a drug that has reduced (if not nearly elimi- of the heart into the arterial circulation within an- nated) their ability to abstain from the highly con- other few seconds. Within 10 seconds, a highly taminated drug delivery system they know may concentrated bullet (bolus) of nicotine-rich blood reaches organs such as the brain as well as the fetus lead to disease and premature death. of a pregnant woman. Arterial blood levels may be The physiological basis of drug dependence be- ten times higher than venous levels within 15 to 20 came increasingly well understood in the past few seconds after smoking. Nicotine arterial boli from decades and especially with regard to nicotine de- smoking a single cigarette may be three to five pendence in the 1970s and 1980s. Awareness of the times more concentrated than the low, steady levels physiology of nicotine dependence can help re- obtained from nicotine gum or patch systems. searchers understand the problems faced by people These spikes probably contribute to the pleasure attempting to give up tobacco and can provide a sought by the cigarette smoker, but, fortunately, more rational basis for the development of treat- they are not necessary to relieve withdrawal symp- ment programs that may prevent the occurrence of toms. NICOTINE GUM and patches, which provide cancer and other diseases or contribute to remission more steady nicotine levels without arterial spikes, in people who have been treated for cancer. may selectively relieve withdrawal without the TOLERANCE as a result of repeated nicotine ex- highly addictive nicotine spikes produced by ciga- posure is a crucial factor in the development of lung rettes. Although SMOKELESS TOBACCO users do not and other cancers. Essentially, smokers self- obtain the same rapid nicotine increase as smokers, they may, by repeatedly putting new ‘‘pinches’’ in administer much greater amounts of tobacco-de- their mouths, achieve stable nicotine levels higher livered toxins than would be the case if they had not than those typical of smokers. developed tolerance. In turn, with development of Most cigarettes on the U.S. market contain 8 to 9 nicotine dependence, smokers come to feel normal, milligrams (mg) of nicotine, and the average comfortable, and most effective when taking the smoker obtains 1 to 2 mg per cigarette. In general, drug and to feel unhappy and ineffective when the type of cigarette or nicotine delivery rating deprived of the drug. This process makes it more reported by the manufacturer bears almost no rela- difficult to achieve and sustain even short-term tion to the level of nicotine obtained by the typical abstinence. TREATMENT: Tobacco, Pharmacotherapy 1203

PHARMACOLOGICAL TREATMENTS Most smokers have quit on their own or, rather, tried to quit. Although 18 million try each year, less than 7 percent do so successfully. Most of the efforts were ‘‘cold turkey,’’ good for a start, but the least effective of all techniques. Long-term abstinence rates are low for people using this method. Treatment programs are helpful in increasing rates of success, and the availability of pharmacological interventions gives clinicians additional useful tools to help the smoker. The major pharmacological approaches are nicotine replacement, symptomatic treatment, nicotine blockade, and deterrent therapy. Nicotine replacement and symptomatic treatment have become part of general medical practice. Until further information is collected, blockade and deterrent therapy must be considered experimental. Nicotine Replacement. The rationale for nicotine replacement is to substitute a safer, more manageable, and, ideally, less addictive (more easily discontinued) form of an abused drug to alleviate symptoms of withdrawal. An example of a less- addictive substitute is METHADONE MAINTENANCE for opiate abusers. Various forms of nicotine replacement have been developed including polacrilex (gum), transdermal delivery systems (patches), nasal vapor inhaler, nasal nicotine spray (gel droplets), and smoke-free nicotine cigarettes. The forms provide different doses and speeds of dosing. These parameters may be important in offering the smoker levels of nicotine necessary to alleviate withdrawal and cravings for nicotine. Currently, only the nicotine gum and patch are approved for use in the United States. Several advantages exist in replacing nicotine from tobacco with non-tobacco-based systems such Figure 1 as gum or patches. First, they do not contain all the Cognitive Performance and an toxins present in tobacco or produced by burning Electrophysiological Measure of Brain Function tobacco. Second, total daily nicotine administra- during Smoking and Abstinence with Nicotine- tion is lower for most patients on nicotine-replace- or Placebo-Delivering Gum Treatment. ment systems, and the high initial nicotine bolus doses produced by inhaling are not delivered. 1984 until 1991, about 1 million prescriptions for Third, the clinician can control doses more effec- nicotine gum, the only form of nicotine replace- tively than with tobacco-based products. The pa- ment then available, were filled per year. At the end tient cannot, for example, take a few extra puffs per of 1991, nicotine patches were introduced, and ap- cigarette and defeat the purpose of gradual nic- proximately 7 million prescriptions were filled for otine-reduction plans. all replacement systems, with the nicotine patch Nicotine gum may not be absorbed well if the accounting for nearly 90 percent of new prescrip- client does not follow directions carefully. From tions for nicotine replacement. The popularity of 1204 TREATMENT: Tobacco, Pharmacotherapy the nicotine patch can be measured by the higher applied to a hairless part of the body, with a differ- rate of compliance than for the only currently ent site every day. The same site should not be used available alternative, nicotine gum. Nicotine gum again for one week. Side effects include a local skin compliance rates tend to be lower because patients reaction at the patch application site in 30 percent may dislike the taste and experience slightly sore of patients and possibly sleep disruption. Because mouths, throats, and jaws and gastrointestinal up- the tobacco-withdrawal syndrome also may in- set. Nevertheless, a study at the Addiction Research clude sleep disruption, it is sometimes difficult to Center of the NATIONAL INSTITUTE ON DRUG ABUSE determine whether the sleep disturbance is a result (NIDA) found nicotine gum to be effective in treat- of tobacco withdrawal or nicotine patch therapy. ing the cognitive function and corresponding brain The four patches vary in their recommendations electrical function changes of tobacco withdrawal. for length of treatment, from six to sixteen weeks. The effect was stronger at higher dose levels (e.g., 4 Because no published studies have documented a mg; see Figure 1). Because of current prescribing benefit for longer treatment, some researchers rec- practices, this section will concentrate on the nic- ommend 6 to 8 weeks for most patients, but ther- otine patch. apy should be individualized where appropriate. Four brands of nicotine patch are currently Other researchers have concluded that, in general, available in the United States. All deliver a given the chances of success appear better in longer-term dose of nicotine transdermally, through the skin, use. over either a 24-hour (Habitrol, Prostep, and In patients with cardiovascular disease, the nic- Nicoderm) or a 16-hour (Nicotrol) period. No clini- otine patch may be used cautiously, although there cal study has directly compared the four brands, has been no documented association between patch but there is no evidence that any one brand leads to use and acute heart attacks. It should be used in consistently higher rates of abstinence than any pregnant patients with caution—only after they other. Variations in nicotine-delivery rate and skin have failed to quit using nondrug means. Nicotine contact effects may mean that certain patches work replacement should not be given to people who better for some people than others, but there is as continue to smoke, although the advisability of ter- yet no way to tell which patch will work better for minating therapy if only occasional cigarettes are an individual patient. smoked is subject to debate. The nicotine patch is highly effective, resulting in Nicotine delivered by tobacco products is one of an overall doubling of smoking cessation rates. Dif- the most highly addictive substances known. Even ferent studies have reported cessation rates of be- people highly motivated to quit may have profound tween 22 percent and 42 percent after six months of difficulty doing so on their own. It is now known use. The combination of intense counseling and that people differ greatly in the severity of their patch use was associated with higher success rates. addictions and their ability to cope. Our ability to Work is necessary to develop a list of character- treat nicotine addiction is continually improving. istics of those patients most likely to benefit from Even so, many people will require several repeated nicotine patch use. The University of Wisconsin’s quitting attempts, regardless of treatment used. Center for Tobacco Research and Intervention sug- Therefore, long-term support by public health or- gests that patients may benefit if they are motivated ganizations and other facilities is essential if we are to quit and fit into at least one of the following to prevent the serious diseases that will affect one in categories: two untreated smokers. Recent data from the 3 million people treated Smoke at least 20 cigarettes per day with the nicotine patch during its first seven Smoke first cigarette within 30 minutes of months of availability in the United States increase awakening optimism that the body can repair much of the Have experienced a strong craving for ciga- damage caused by smoking. Epidemiological data rettes during the first week of previous indicate that 2,250 heart attacks would have oc- attempts at quitting curred if these smokers had continued their habit. The nicotine patch should be applied as soon as In fact, the Food and Drug Administration (FDA) the patient awakens, and the user should stop all received reports of only 33 severe cardiovascular smoking during patch use. The patch should be problems. Even assuming underreporting, this de- TREATMENT: Tobacco, Pharmacotherapy 1205 crease is so profound that it strongly supports the or psychomotor stimulants may improve absti- conclusion of the surgeon general in 1991 that risk nence rates. The benzodiazepine tranquilizer of heart attacks rapidly declines after smoking ces- alprazolam was also examined by Glassman and sation. These people were receiving nicotine via the his colleagues (1984; 1988) and found to reduce patch, although probably at a lower level than if anxiety, irritability, tension, and restlessness, but it they continued smoking, and still their rate of heart had no effect on cravings for cigarettes in heavy attacks was significantly reduced. users abstaining from smoking for one day. More Symptomatic Treatment. Nicotine adminis- study is necessary on its effectiveness in maintain- tration and withdrawal produce a number of ing tobacco abstinence. neurohormonal and other physiological effects. Nicotine Blockade. Nicotine blockade ther- Symptomatic treatment methods are nonspecific apy is based on the rationale that if one blocks the pharmacotherapies to relieve the discomforts and rewarding aspects of nicotine by administering an mood changes associated with withdrawal. If the antagonist (or blocker), the smoker who seeks the potential quitter relapses to escape the suffering of pleasant effects nicotine produces will be more withdrawal, these methods should help to prevent likely to stop. To be effective, the drug must be such relapse. There is a long history of pharmaco- active in the central nervous system (brain and logical treatment of smokers. To reduce with- spinal cord). Thus mecamylamine, which acts at drawal, sedatives, tranquilizers, anticholinergics, both central and peripheral nervous system sites, sympathomimetics, and anticonvulsants have all effectively increases rates of abstinence, whereas been tried at one time and were no more successful hexamethonium and pentolinium, which block pe- in helping smokers quit than was a placebo. CLONI- ripheral nervous system receptors only, have no DINE is one agent that has been tried in the treat- effect on abstinence. The problem is that there are ment of nicotine withdrawal discomfort and is no pure nicotine antagonists currently available. commonly used to treat opioid withdrawal. Drugs like mecamylamine produce side effects, Glassman and his colleagues (1984; 1988) admin- such as sedation, low blood pressure, and fainting, istered clonidine to heavy smokers on days they that probably limit their role to that of an experi- abstained from smoking and found that it reduced mental tool, not appropriate for clinical treatment. anxiety, irritability, restlessness, tension, and Deterrent Therapy. The rationale for deter- craving for cigarettes. When they gave clonidine to rent therapy is that pretreatment with a drug may smokers trying to quit, 6 months later, 27 percent transform smoking from a rewarding experience to of those given clonidine and 5 percent of those an aversive one if the unpleasant consequences are given placebo reported abstinence. Surprisingly, immediate and strong enough. DISULFIRAM treat- clonidine seemed to be effective only for women. ment for alcoholism is an example of this type of Among men, those given clonidine did no better treatment. After pretreatment, even a small quan- than those given a placebo. Before recommending tity of alcohol can produce discomfort and acute clonidine for smokers, practitioners should con- illness. Silver acetate administration is a potential sider potential side effects. Clonidine has been used treatment for smokers. When silver acetate con- to treat hypertension, and abrupt termination has tacts the sulfides in tobacco smoke, the resulting sometimes led to severe hypertension and in rare sulfide salts are highly distasteful to most people. circumstances to hypertensive encephalopathy and Although many over-the-counter deterrent prod- death. More commonly, it may cause drowsiness, ucts are available, their effectiveness has not been potentially dangerous to someone operating ma- scientifically validated. Additionally, a severe limi- chinery or driving. tation to this treatment is compliance. It may be Among nicotine’s effects is the regulation of difficult to ensure that patients continue to take the mood. Smokers have been shown to smoke more medication as needed. than usual during stressful situations; therefore, those trying to quit often relapse (begin smoking BEHAVIORAL TREATMENTS again) during stressful situations. These observations suggest that treating the mood changes asso- Characteristics of tobacco dependence and nic- ciated with abstinence with, for example, otine addiction suggest that combining nicotine re- BENZODIAZEPINE tranquilizers, ANTIDEPRESSANTS, placement, to reduce the physiological disruptions 1206 TREATMENT: Tobacco, Pharmacotherapy of withdrawal, with behavioral treatments, to withdrawal symptoms when the client stops smok- counter the conditioning cues, reinforcers, and so- ing. Problems are that the procedure may do noth- cial context cues associated with smoking, may be ing to reduce cravings (considered important for especially useful in helping people to quit. Adding relapse prevention) and that the nicotine reduction behavioral treatments may increase both the rate of is not as large as one would expect from ratings of successful outcomes and the adherence to the phar- the cigarettes’ contents, because people change the macological treatment. Behavioral interventions way they smoke to receive more nicotine from each for smokers have been tried for many years. This cigarette. Improved outcomes may occur with nic- section will focus on several of the current major otine fading when it is part of multicomponent approaches, but it is by no means comprehensive. treatment approach. Social support has produced mixed results. En- Aversion treatments are designed to condition a listing the help of the smoker’s spouse and cowork- distaste for cigarettes by pairing smoking with ei- ers, or encouraging participation in a group, has ther unpleasant imagery (covert sensitization), yielded generally positive outcomes, but attempts electric shock, or unpleasant effects of smoking to enhance social support further have been uni- itself through directed smoking procedures. Di- formly unsuccessful. Providing skills training in rected smoking techniques include satiation, rapid coping with stress and negative emotions has also smoking, and focused smoking. In satiation, clients been tried but generally as part of a multicompo- smoke at least at twice their regular rate. Research nent treatment plan. If the person smokes during indicates a low, 15 percent success rate when sa- times of stress and negative emotions, learning tiation is used by itself, versus 50 percent when it is other means of dealing with these situations may part of a multicomponent program. In rapid smok- lessen the need to smoke. Skills training appears ing, clients inhale every 6 seconds until they will get beneficial in the short term, especially when com- sick, usually for six to eight sessions. As part of a bined with aversive smoking procedures (discussed multicomponent program, good outcomes are seen, below), but its long-term benefits are less clear. but success is variable when rapid smoking is used Mixed but generally negative results have been re- alone, with high immediate abstinence rates, fol- ported, but a problem in assessing skills training is lowed by low long-term rates. In focused smoking, that researchers have not controlled for the differ- clients either smoke for a sustained period at a slow ences in treatments available. Some may be more or normal rate or do rapid puffing without inhaling. effective than others. The techniques should be Long-term outcomes are similar to or slightly lower available for clients long after learning in order to than for rapid smoking. The utility of aversion probe beneficial for long-term smoking cessation. cedures is limited because the aversions are rarely Contingency contracting uses operant condi- permanent, and it is difficult to condition aversion tioning techniques to reinforce quitting or punish to a substance that has had repeated past use. smoking behaviors. Procedures include collecting monetary deposits from clients early in treatment CONCLUSIONS and providing periodic repayment as nonsmoking goals are reached, having a client pledge to donate Multicomponent interventions that combine money to a disliked organization for every cigarette pharmacological and behavioral components ap- smoked, or similar procedures using nonmonetary pear to be the best treatment strategies, often pro- rewards or punishers. Research indicates that con- ducing very high short-term (nearly 100% for the tingency contracting aids quitting at least in the best programs) and impressive long-term success short term. Stimulus control procedures gradually rates (at or above 50%). Ideally, the components eliminate situations in which the client smokes should complement one another; however, it is not (e.g., only smoke outside) or the time the client known how the separate components work in com- smokes (e.g., only on the half hour) to reduce the bination. It is possible that, because people smoke number of cues for smoking. for different reasons (to prevent withdrawal, to Nicotine fading gradually changes brands or cig- ease anxiety, to relax, to achieve pleasant effects), a arette filters the smoker uses, in order to decrease program that includes components that target tar and nicotine per cigarette before complete ces- enough different reasons for smoking will be suc- sation. It is hoped this strategy will decrease later cessful in most cases. Second, it is not known which TREATMENT: Tobacco, Psychological Approaches 1207

components work best together or how to target NATIONAL CANCER INSTITUTE. (2000). Questions and An- interventions for particular types of people. Third, swers About Finding Smoking Cessation Services. Be- a concern in designing a multicomponent treatment thesda, MD: Office of Cancer Communications. plan is that too many interventions may decrease PALMER, K. J., BUCKLET, M. M., & FAULDS, D. (1992). patient compliance. Despite these gaps in our Transdermal nicotine: A review of its phar- knowledge, smoking-cessation programs are im- macodynamic and pharmacokinetic properties, and proving constantly, and smokers do not have to go therapeutic efficacy as an aid to smoking cessation. it alone in their attempts to quit. Drugs, 44, 498–529. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. (1991). Strategies to control tobacco use in the United (SEE ALSO: Addiction: Concepts and Definitions; States: A blueprint for public health action in the Nicotine Delivery Systems for Smoking Cessation; 1990’s. In D. R. Shopland et al. (Eds.), Smoking and Relapse Prevention; Tobacco; Treatment Types) tobacco control monographs no. 1. U.S. Public Health Service, NIH Pub. No. 92-3316. Washington, DC: BIBLIOGRAPHY U.S. Government Printing Office. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. BEERS, M. H., & BERKOW, R. (Eds.) (1999). The Merck (1988). The health consequences of smoking: Nic- Manual of Diagnosis and Therapy, 17th ed. otine addiction. A report of the surgeon general. U.S. Whitehouse Station, NJ: Merck Research Laborato- Public Health Service, DHHS Pub. No. (CDC) ries. 88-8406. Washington, DC: U.S. Government Printing BENOWITZ, N. L. (1992). Cigarette smoking and nicotine Office. addiction. Medical Clinics of North America, 76, 415– WILSON, B. A., SHANNON, M. T., & STANG, C. L. (Eds.) 437. (1995). Nurses Drug Guide, 3rd ed. Norwalk, CT: FIORE, M. C., ET AL. (1992). Tobacco dependence and Appleton & Lange. the nicotine patch: Clinical guidelines for effective LESLIE M. SCHUH use. Journal of the American Medical Association, JACK E. HENNINGFIELD 268, 2687–2694. REVISEDBY REBECCA J. FREY GLASGOW, R. E., & LICHTENSTEIN, E. (1987). Long-term effects of behavioral smoking cessation interventions. Behavior Therapy, 18, 297–324. GLASSMAN, A. H., ET AL. (1988). Heavy smokers, smok- Tobacco, Psychological Approaches ing cessation, and clonidine: Results of a double blind, Persistent use of tobacco products is believed to randomized trial. Journal of the American Medical result from the rewarding effects of nicotine, a psy- Association, 259, 2863–2866. chostimulant found in tobacco. Individuals become dependent on tobacco, in part, because of nicotine’s HARDMAN,J.G.,&LIMBIRD, L. E. (Eds.) (1996). Good- positive psychoactive effects (e.g., mild euphoria, man and Gilman’s the pharmacological basis of ther- stimulation, improved concentration). Continued apeutics, 9th ed. New York: McGraw-Hill. use of tobacco products is also reinforced by the HENNINGFIELD, J. E., LONDON,E.D.,&BENOWITZ,N.L. alleviation of unpleasant withdrawal symptoms (1990). Arterial-venous differences in plasma con- that often occur during nonuse or abstinence (e.g., centrations of nicotine from nicotine polacrilex gum. irritability, weight gain). However, tobacco depen- Journal of the American Medical Association, 263, dence results not only from the pharmacological 2049–2050. effects of nicotine that eventually lead to physical JARVIK, M. E., & HENNINGFIELD, J. E. (1993). Pharmaco- addiction, but also from the psychological and be- logical adjuncts for the treatment of nicotine depen- havioral components associated with tobacco use. dence. In J. D. Slade and C. T. Orleans (Eds.), Nic- Psychological reliance on tobacco is likely to be a otine addiction: Principles and management. result of the psychoactive effects from nicotine and London: Oxford University Press. the use of tobacco. For example, a cigarette smoker MEDICAL ECONOMICS COMPANY. (1999). Physicians’ Desk may smoke to modulate moods or deal with stress. Reference, (PDR), 53rd edition. Montvale, NJ: Au- The behavioral components are a result of learning thor. that certain contexts or stimuli are associated with 1208 TREATMENT: Tobacco, Psychological Approaches smoking behavior with consequent desirable ef- section are most applicable to the action stage. At fects. After repeated self-administration of nic- all stages of change, education about nicotine de- otine-containing tobacco products, these contexts pendence is essential. Education about nicotine de- or stimuli begin to control behavior. Pharmacologi- pendence should emphasize a couple of major cal treatments are often used to deal with the physi- points. First, chronic use of nicotine changes the cal addiction to nicotine. However, psychological or brain, leading to a complex neurobiological disor- behavioral approaches are used to help smokers der. Second, nicotine withdrawal is a difficult but learn more adaptive ways to deal with situations time-limited syndrome typically taking one to three other than using tobacco products and to engage in weeks to subside, with weight gain and cravings more adaptive behavior in response to stimuli asso- persisting longer. Nicotine withdrawal can involve ciated with smoking. negative mood, insomnia, anxiety, impaired atten- This section will discuss assessing whether to- tion and concentration, restlessness, and weight bacco users are ready to quit tobacco products, gain. Knowing why one uses tobacco and what lies methods to motivate them to quit, and behavioral ahead as well as knowing that effective treatment treatment methods that have been found to be ef- techniques are available, can help to motivate a fective, and combining pharmacological and be- quit attempt and enhance self-efficacy, the belief havioral treatment approaches. that one has the ability and tools to achieve abstinence from tobacco. For those in the action stage, ASSESSMENT OF READINESS TO QUIT providing counseling that involves problem solving TOBACCO USE and developing coping skills is most effective. The application of behavioral treatments to tobacco-dependent individuals begins with an assess- PRINCIPLES OF ment of preparation for change. Readiness to BEHAVIORAL MODIFICATION change negative health behaviors has conceptu- Classical behavioral treatments in tobacco ces- alized in the transtheoretical model originated by sation are based on the principles of behavioral James Prochaska and Carlos DiClemente. This modification, where the antecedents and the conse- model posits that there are reliable Stages of quences of tobacco-use behavior are examined. Change in health awareness and motivation, and Consequences are events that occur after the use of that appropriate treatments vary by the stage. tobacco. If the consequences increase behavior, There are five stages of change: (1) pre- then the process is termed reinforcement. There are contemplation, a period where during the next 6 two major types of reinforcement: positive and neg- months, the tobacco user is not considering quitt- ative. Positive reinforcement involves the presenta- ing; (2) contemplation, a period when a tobacco user is seriously considering quitting in the next 6 tion of an event that then increases behavior. Nega- months; (3) preparation, a period when, a tobacco tive reinforcement involves the removal of an event user who tried quitting in the previous year, thinks that also results in increased behavior. about quitting in the next month; and (4) action, a Both positive and negative reinforcements initi- 6 month period after the tobacco user makes overt ate and maintain tobacco use. Positive reinforce- changes to stop using tobacco products. The last ment from smoking cigarettes, for example, may stage, maintenance, is the longest and describes the include improving concentration. Negative rein- tobacco-free period after cessation. To assess stage forcement from smoking cigarettes may include re- of change, informal questioning or a brief list of duction of tension, depressed mood, or prevention structured questions (i.e., the University of Rhode of withdrawal symptoms. Island Assessment Scale [URICA]), has been em- If the consequence decreases behavior, then the ployed. process is termed punishment. Punishment can in- At any time, the majority of smokers are pre- volve presentation of an event or removal of an contemplators, contemplators, or preparers, and event. For example, the occurrence of social disap- these individuals lack the motivation to justify the proval, negative physical consequences, and in- intensive behavioral techniques described below. creased cigarette taxes may reduce smoking. Simi- The behavioral techniques described later in this larly, the removal of privileges, such as being TREATMENT: Tobacco, Psychological Approaches 1209 unable to participate in sports can decrease smok- approaches represent supportive psychological ing behavior and serve as punishment. treatments, whereas the latter two emphasize be- Despite the many negative consequences of to- havioral aspects of smoking and employ some prin- bacco use, it often persists in many who try it. ciples of behavioral modification. Before consider- There are many antecedents or events that precede ing them, the actual act of quitting and relevant tobacco use, that begin to control or maximize the approaches are detailed. Finally, brief descriptions occurrence of tobacco use, the process called stimu- of some techniques whose clinical efficacy has not lus control. An individual learns that in certain been supported will be provided. situations, behavior is reinforced; while in other situations, it is either not reinforced or punished. QUITTING For example, a smoker may learn smoking in bars is reinforced socially as well as by nicotine’s effects, Several techniques have been developed to help whereas smoking in church is not reinforced. Upon the individual quit using tobacco products. One repeated experiences, frequenting bars begins to technique, quitting abruptly (‘‘cold turkey’’), is automatically elicit the desire or behavior for best executed on a planned quit day and as part of a smoking, while in contrast attending church does broader treatment strategy (e.g., involving intra- not. In large part, the punishing effects of tobacco treatment support). In contrast, gradual reduction use and particularly the reinforcing effects of cessa- involves slowly reducing tobacco use until it tion are relatively remote (i.e., occur years in the reaches zero. Several reduction approaches are future), while the reinforcing consequences of available including one where the number of ciga- smoking (e.g., mood regulation) are more immedi- rettes smoked each day is reduced (either through ate. The strength of any reinforcer or punishment lengthening the time between cigarettes or delaying diminishes the further removed from the actual be- the onset of smoking) and one where situations havior, and thus tobacco use is often maintained where tobacco is used are slowly restricted. Unfor- for decades. tunately, a significant number of smokers experi- Behavioral treatments involve manipulating ence difficulty in reducing the number of cigarettes these antecedents and consequences to reduce the beyond a certain point. Other gradual reduction probability of tobacco use. Further, skills that fos- methods include using cigarette filters with ventila- ter non-tobacco use behaviors such as stress man- tion holes that can decrease the amount of nicotine agement skills and assertiveness are also taught or obtained from each cigarette or gradually reducing encouraged. the nicotine content of the cigarette. However, these methods may result in compensatory smoking, that is puffing more or longer, or smoking more BEHAVIORAL, SUPPORTIVE, AND cigarettes to make up for reduced nicotine. An OTHER TREATMENTS important goal of tobacco reduction methods is the Since the 1960s, many behavioral techniques reduction of withdrawal signs and symptoms from have been developed to help tobacco dependent tobacco, which gradual reduction does in fact people quit, but only a few techniques have shown achieve. However, gradual reduction may prolong reliable evidence of efficacy. Efficacy is generally withdrawal symptoms for a period longer than defined by comparing abstinence rates (i.e., pro- abrupt cessation. portion not using tobacco products) at six months Since the 1980s, a number of pharmacological or a year after quitting. In 2000, the Agency for agents have been developed for the treatment of Health Research and Quality (AHRQ) released a smokers. Nicotine replacement therapies (e.g., nic- second comprehensive evaluation of these tech- otine gum) and novel non-nicotine phar- niques using meta-analysis, a method of quantita- macotherapies, such as buproprion (Zyban) have tive literature review. The review identified four been found to significantly reduce withdrawal signs areas of behavioral treatment or psychosocial sup- and symptoms. Because of the uniform efficacy of port that were associated with significantly higher these products, their use has been recommended quit rates: (a) intra-treatment support; (b) extra- for most smokers to aid cessation (excluding treatment support; (c) problem solving and skills smokers who have certain medical illnesses, preg- training; and (d) aversive techniques. The first two nant women, or adolescents). 1210 TREATMENT: Tobacco, Psychological Approaches

In summary, tobacco users are typically advised solving includes learning how to assess potential to set a quit date and to take medications to assist in relapse situations adequately, developing a number their cessation efforts. If a smoker does not want to of solutions, and trying out these solutions. Solu- use medications, abrupt cessation can be used or if tions involve the use of coping skills. One type of the smoker is concerned about withdrawal, a grad- coping skill is learning how to deal with stimulus ual approach may be taken. control or high-risk situations. One method is to avoid stimuli associated with tobacco, such as the INTRA-TREATMENT AND smoking section of a restaurant. Also, smokers can EXTRA-TREATMENT SUPPORT put themselves in situations that prevent or discourage tobacco use (e.g., movie theatre, non- The process of quitting smoking can be difficult, smoking restaurant). Unavoidable situations and and support and encouragement can greatly help. psychological states can be countered through cog- In intra-treatment support, healthcare providers nitive strategies such as distraction and positive (e.g., physicians) improve quit-rates through sup- thinking. Other techniques include using substi- port and encouragement (e.g., by recognizing the tutes that may simulate some of the stimulus quali- discomfort of quitting, underscoring that half of all ties or effects of smoking (e.g., chewing gum, suck- smokers have quit for good, and noting that effec- ing on straws). In addition, craving to use tobacco tive therapies exist). In addition, by providing products lasts only minutes, and using distractions training in acquiring extra-treatment support, the (e.g., exercising) can occupy the tobacco user until tobacco user can effectively obtain additional care the craving passes. Tobacco users are also taught to from family members, friends, and telephone hot- practice refusing tobacco or asking others not to lines. Further, supportive others (e.g., spouse) can use tobacco around them. Often tobacco users have be contacted with information on tobacco cessation employed nicotine instead of coping skills that or encouraged to participate directly in treatment could be used to counter stress and negative affect, with the tobacco user. and training in use of adaptive coping skills can be beneficial. PROBLEM SOLVINGAND The deprivation of nicotine and tobacco can be SKILLS TRAINING offset by the provision of rewards. Rewards can include saving money that is typically spent on Problem solving and skills training involve cigarettes to reinforce the cost of the habit and to learning to recognize patterns of tobacco use and pay for pro-health activities like vacations. Re- situations where use is common through self-moni- wards can also be leisure activities (e.g., reading a toring and learning ways to effectively deal with book, going to a movie). Finally, rewards can be these high risk situations. self-affirming statements such as, ‘‘I did really well Self-monitoring requires an individual using to- today.’’ Rewards are initially given for small suc- bacco products to monitor situations and feelings cesses, based on achieving a goal behavior (e.g., not that are associated with tobacco use. Through self- smoking for 72 hours), and occur as soon as possi- monitoring, the individual begins to recognize spe- ble upon completion of this behavior. cific antecedent conditions that are associated with the use of tobacco. Antecedent conditions for a cigarette smoker often involve environmental AVERSIVE TECHNIQUES contexts or situations (e.g., smoking the first thing Rapid smoking is one aversive technique that in the morning) while others involve internal cues has been found effective. Smokers are asked to or psychological states (e.g., being under pressure). smoke several consecutive cigarettes rapidly so that In these situations, tobacco users are most likely to they will experience immediate adverse, punishing experience craving or an urge to use tobacco prod- effects (e.g., nausea), thereby reducing the desire to ucts. Understanding and recognizing these situa- smoke. Similarly, reduced-aversion techniques also tions and psychological states will promote learning facilitate smoking cessation by their unpleasant skills to handle them. effects and improve the effectiveness of behavioral Adequate problem solving and coping skills are treatment. This technique involves focusing on essential to remaining tobacco free. Problem smoking while the person smokes for a sustained TREATMENT: Tobacco, Psychological Approaches 1211 period of time, or on rapid puffing with no inhala- generally lead to relapse. Therefore, smokers or tion of the smoke. tobacco users are instructed not allow themselves use of any tobacco products (e.g., not one puff). OTHER TECHNIQUES Maintaining abstinence involves developing both behavioral and cognitive skills that go beyond the Several other techniques for tobacco cessation initial challenges of nicotine withdrawal. Long have failed to show results superior to a non-treat- term abstinence may be supported through health- ment control group, but may still be useful in treat- oriented lifestyle changes such as increased levels of ment programs that employ multiple behavioral physical activity, proper eating, obtaining enough techniques. Relaxation or breathing techniques in- sleep and rest, and managing or changing levels of volve deep breathing or meditation in anticipation stress in adaptive ways. or response to urges to use tobacco. Programs designed to specifically counter negative affect seek to help the tobacco user to identify negative feelings, CONCLUSION assess and appraise the situations that lead to the Many of the techniques used in psychological negative affect, and respond to them realistically treatment for smoking cessation have been de- and productively. Programs designed to counter in- scribed in this article. Studies show that smoking creased weight on cessation (on average about interventions are most effective when multiple seven pounds), have not improved quit rates, and techniques are used, and that increasing treatment can actually reduce the chances of successfully contact can further improve treatment outcome. quitting. Two commercial treatments, hypnosis Unfortunately, nicotine is a highly addictive drug, and acupuncture continue to be popular, but their and relapse to smoking cigarettes or other tobacco lack of efficacy and unclear bases for action do not use remains high, in spite of behavioral treatment support their use. and pharmacological interventions. Following treatment, most tobacco users begin to relapse with INTENSITY OF only twenty to thirty percent still tobacco free after BEHAVIORAL TREATMENT six months from quitting. Use of both pharmacotherapies and psychologi- A separate question from which behavioral treatments to give is how much or how intense the cal treatments for smoking cessation can increase treatment should be? Treatment intensity involves success rates, with combinations used to target the number of treatment sessions, the length of different aspects of nicotine addiction. For exam- these sessions, and also the total amount of time ple, pharmacotherapies such as nicotine gum or spent throughout treatment providing behavioral bupropion reduces the physical dependence aspects treatments and support. The AHRQ guideline rec- of smoking, which then allows the tobacco user to ommends that an intensive treatment should in- focus on the behavioral or psychological aspects of clude four or more sessions, with each session last- smoking. The intensity of behavioral treatment and ing at least ten minutes, and that the total contact whether pharmaceutical treatments are prescribed time should be longer than thirty minutes. Pro- depends on the characteristics of the smoker (e.g., viding additional contact time and support will in- degree of dependence). crease quit rates, but need to be weighed against In order to help tobacco users receive treatment the financial costs and likely loss of patient partici- appropriate to their stage of change and tobacco pation if the contact is spread of many weeks. and health histories (i.e., level of nicotine dependence, previous quit attempts), a stepped care model has been proposed. In the stepped care RELAPSE PREVENTION framework, a process called tailoring is used so that Once a tobacco user has quit consuming to- the most appropriate treatment is given. Those in bacco, the challenge is to prevent relapse, the re- the precontemplation, contemplation, and action turn to regular tobacco use. Relapse is distin- stages are given information about the health risks guished from a slip, which is smoking one or few of tobacco use, the benefits of cessation, resources cigarettes after a period of abstinence. However, for a later quit attempt, and a follow-up is planned slips, especially during the initial weeks of quitting, to reassess their readiness to quit. When tobacco 1212 TREATMENT: Tobacco, Psychological Approaches

users make an initial quit attempt a minimum of Handbook of Health Behavior Research II: Provider intra-treatment behavioral support is used, in con- Determinants. Plenum Press: New York. junction with self-help materials and if necessary HALL, S. M., RUGG, D., TUNSTALL, C., ET AL. (1984). pharmacotherapy is recommended. Tobacco users Preventing relapse to cigarette smoking by behavioral who have failed to quit with less intensive treat- skill training. Journal of Consulting & Clinical Psy- ments can then be ‘‘stepped up’’ to a program chology, 52, 372–82. involving more contact, different behavioral inter- HATSUKAMI,D.K.,&LANDO, H. A. (1993). Behavioral ventions, and pharmacotherapies. In all cases, treatment for smoking cessation. Health Values, 17, planned follow-up is essential to determine if addi- 32–40. tional treatment is needed. HATSUKAMI,D.K.,&MOONEY, M. E. (1999). Pharmaco- Of ﬁnal note, most cigarette smokers quit on logical and behavioral strategies for smoking cessa- their own, without treatment, but their quit rates tion. Journal of Clinical Psychology in Medical Set- are the lowest of any approach (e.g., compared to tings, 6, 11–38. behavioral or pharmacological treatments). If HUGHES, J. R. (1995). Combining behavioral therapy smokers do seek treatment, they tend to obtain help and pharmacotherapy for smoking cessation: an up- from their physician or from health-care providers date. NIDA Research Monograph, 150, 92–109. who often do not have time to provide intensive HUGHES, J. R. (2000). Reduced smoking: An introduc- behavioral treatment. Therefore, availability and tion and review of the evidence. Addiction, 95 use of the behavioral techniques for smoking cessa- (Suppl.), S3–S7. tion are being increasingly adapted to these various HUGHES, J. R., GOLDSTEIN, M. G., HURT,R.D.,ET AL. methods or settings for tobacco cessation (e.g., (1999). Recent advances in the pharmacotherapy of teaching smokers how to obtain extra-treatment smoking [see comments]. Jama, 281(1), 72–6. support, such as through telephone counseling). KLESGES, R. C., & SHUMAKER SA. (1992). Understanding Telephone counseling is a particularly promising the relations between smoking and body weight and source of treatment support that can provide inten- their importance to smoking cessation and relapse. sive counseling without the need for costly travel Health Psychology, 11 (Suppl.),1–3. and missed work. Recently, awareness that tobacco LICHTENSTEIN, E., GLASGOW, R. E., LANDO, H. A., ET AL. cessation is not possible for all individuals, at least (1996). Telephone counseling for smoking cessation: as the initial goal in treatment, has given rise to Rationales and meta-analytic review of evidence. studies of tobacco use reduction. The role for psy- Health Education Research, 11, 243–257. chological treatments in this burgeoning area is not LICHTENSTEIN, E., GLASGOW, R. E., & ABRAMS,D.B. clear but will doubtless be important. In the long (1986). Social support in smoking cessation: In run, however, societal pressures (e.g., banning search of effective interventions. Behavior Therapy, smoking in public places) and economic pressures 17, 607–619. (e.g., increasing taxes on tobacco products) will LICHTENSTEIN, E., & GLASGOW, R. E. (1992). Smoking likely have the greatest impact in reducing tobacco cessation: What have we learned over the past dec- use and in encouraging cessation. ade? Journal of Consulting and Clinical Psychology, 60, 518–527. BIBLIOGRAPHY MCCONNAUGHY, E. A., PROCHASKA, J. O., & VELICER, FIORE, M. C., NOVOTNY, T. E., PIERCE, J. P., ET AL. W. F. (1983). Stages of change in psychotherapy: (1990). Methods used to quit smoking in the United Measurement and sample proﬁles. Psychotherapy: States. Do cessation programs help? Journal of the Theory, Research, and Practice, 20, 368–375. American Medical Association, 263, 2760–5. POMERLEAU, O. F., & POMERLEAU, C. S. (1987). Break FIORE, M. C., BAILEY, W. C., COHEN, S. J,. ET AL. (2000) the smoking habit. A behavioral program for giving up Treating tobacco use and dependence. Clinical prac- cigarettes. Ann Arbor: Behavioral Medicine Press. tice guideline. Rockville, MD: U.S. Department of PROCHASKA, J. O., DICLEMENTE, C. C., & NORCROSS,J.C. Health and Human Services. Public Health Service. (1992). In search of how people change. Applications GLASGOW, R. E., & ORLEANS, C. T. (1997). Adherence to to addictive behaviors. American Psychologist, 47(9), smoking cessation regimens. Eds. David S. Gochman. 1102–14. TREATMENT: Twelve Step Facilitation (TSF) 1213

SHIFFMAN, S. (1984). Coping with temptations to smoke. pro-recovery behavioral work that the patient Journal of Consulting and Clinical Psychology, 52, agrees to undertake between sessions. 261–267. The various TSF interventions, or ‘topics’ are of SHIFFMAN, S., READ, Laura, R., MALTESE, J., ET AL. two types: Core and Elective. Core sessions include (1985). Preventing relapse in ex-smokers. In G.A. Introduction & Assessment, Acceptance, People, Marlatt and J.R. Gordon (Eds.), Relapse prevention: Places, & Routines, Surrender, Getting Active. Maintenance strategies in the treatment of addictive Elective (advanced) sessions include: Genograms, behaviors. New York: Guilford Press. Enabling, Emotions, Moral Inventories, Relation- U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. ships. There is also a conjoint program. (1994). Tobacco and the clinician: Interventions for Patients need not necessarily be dependent on medical and dental practice. NIH Publications no. either alcohol or drugs in order to benefit from a 94-3693. Washington, D.C: Author. 12-step oriented treatment; rather, they must U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. merely satisfy the basic criterion for becoming (1991). Strategies to control tobacco use in the member of a 12-step fellowship as set forth by United States: A blueprint for public health action in Alcoholics Anonymous, namely, ‘‘a desire to stop the 1990s. NIH Publications no. 92-3316. Washing- drinking,’’ or to stop using drugs (Alcoholics Anon- ymous, 1952). However, 12-step fellowships do ton, D.C: Author. advocate abstinence, as opposed to controlled use JONI JENSEN of alcohol or drugs. Historically, these fellowships DOROTHY HATSUKAMI were founded and exist to provide support and REVISEDBY MARC E. MOONEY advice, and to facilitate the personal growth of individuals whose own efforts to control their use of alcohol and/or drugs have failed and whose lives Twelve Step Facilitation (TSF) Twelve have became ‘‘unmanageable’’ as a consequence of Step Facilitation (Nowinski & Baker, 1998; substance abuse (Alcoholics Anonymous, 1976). Nowinski, Baker, & Carroll, 1992) is a manual- guided, twelve-step based treatment program that EARLY RECOVERY includes a range of interventions that are organized Based on an assessment of the patient’s lifestyle, into a ‘‘core’’ or basic program, an ‘‘elective’’ or prior treatment experiences, periods of sobriety, advanced program, and a brief conjoint program and circumstances surrounding relapse, an individ- for the substance abuser and a significant other. ual treatment plan is devised, typically including Interventions in the core program are most appro- one or more elective topics plus the core TSF propriate for what could be termed the ‘‘early’’ or gram. Broadly speaking, early recovery can be bro- initial stage of recovery from alcohol or drug de- ken down into two phases: acceptance and surren- pendence, meaning that stage of change in which der. Acceptance refers to the process in which the an individual takes their initial steps from active individual overcomes ‘‘denial.’’ Denial refers to the substance abuse toward abstinence. personal belief that one either does not have a sub- TSF is a highly structured intervention whose stance abuse problem, and/or that one can effec- sessions follow a prescribed format. Each begins tively and reliably control drinking or drug use. with a review of the patient’s recovery week, in- Acceptance represents a significant insight: That cluding any 12-step meetings attended and reac- one has in fact lost the ability to effectively control tions to them, episodes of drinking or drug use use of alcohol or drugs. Acceptance is marked by a versus sober days, urges to drink or use, reactions realization that one’s life has become progressively to any readings completed, and any journaling that more unmanageable as a consequence of alcohol or the patient has done. The second part of each TSF drug use, and furthermore that individual session consists of presenting new material, consist- willpower alone is an insufficient force for creating ing of material drawn from the core, elective, or sustained sobriety and restoring manageability to conjoint program. Each session ends with a one’s life. Given this realization, acceptance implies wrap-up that includes the assignment of recovery that the only sane alternative to continued chaos tasks: readings, meetings to be attended, and other and personal failure to admit defeat (or one’ s ef- 1214 TREATMENT: Twelve Step Facilitation (TSF) forts to control use), and to accept the need for tried to carry this message to alcoholics, and to abstinence as an alternative to controlled use. This practice these principles in all our affairs’’ (Alco- is Step I of Alcoholics Anonymous: ‘‘We admitted holics Anonymous, 1952). AA and its sister we were powerless over alcohol—that our lives had 12-Step fellowships have a long spiritual tradition, become unmanageable’’ (Alcoholics Anonymous, in that they challenge individuals to believe in a 1976). center of power that is greater than personal As important as insight is, alone it is not suffi- willpower. This ‘‘Higher Power’’ may be the fellow- cient for recovery, and that is where the concept of ship itself. Substituting faith in the group (or some surrender comes in. Surrender refers to a willing- other higher power) for faith in personal willpower, ness to take action, and specifically to embrace the is the essence of 12-Step recovery, and it has been twelve steps as a guide for recovery and spiritual likened to a form of spiritual conversion or renewal. These are Step 2 and 3: We came to awakening (Fowler, 1993). 12-Step fellowships believe that a Power greater than ourselves could believe that those who thoroughly follow their pro- restore us to sanity; We made a decision to turn our gram of recovery will eventually benefit spiritually: will and our lives over to the care off God as we That they will re-evaluate themselves in terms of understood Him (Alcoholics Anonymous, 1976). how they relate to others, their personal goals, and AA and NA are programs of action and lifestyle their sense of purpose in life. change, as much as they are programs of insight and spiritual renewal. Surrender follows acceptance and represents the individual’s commitment EFFICACY OF 12-STEP to making whatever changes in lifestyle are neces- BASED TREATMENT sary in order to sustain recovery. Surrender re- TSF has been found to be effective in producing quires action, including frequent attendance at AA significant and sustained reductions in alcohol use and/or NA meetings, becoming active in meetings, (Project MATCH Research Group, 1997; Seraganian reading AA/NA literature, getting a sponsor, making et al., 1998). A further finding from Project AA/NA friends, and replacing people, places, and MATCH, and supported by other research routines that have become associated with sub- (Fiorentine, 1999), is a correlation between attend- stance abuse and therefore represent a threat to ance at 12-step meetings and abstinence from alco- recovery, with alternative relationships and habits hol and drug use. Finally, greater involvement in of living. In TSF the action and commitment that 12-step fellowships (e.g., getting a sponsor, taking are the hallmarks off surrender are guided to some on responsibilities) has been found to correlate pos- extent by the facilitator; but they are also heavily itively with recovery (Emrick, 1993). Taken to- influenced by individuals the patient encounters gether, these studies offer empirical support for the and begins to form relationships with within efficacy of these widely used models of treatment, 12-Stop fellowships. One especially significant re- particularly when therapists are trained to deliver lationship that TSF actively advocates for in early recovery is that of the sponsor, who is someone this manualized approach competently. already in recovery and active in a fellowship who offers guidance and support to the newcomer. BIBLIOGRAPHY

ALCOHOLICS ANONYMOUS (1976). Alcoholics anonymous: SPIRITUALITY The story of how many thousands of men and women Twelve step fellowships regard spirituality as a have recovered from alcoholism (3rd ed.). New York: force that provides direction and meaning to one’s Alcoholics Anonymous World Services. life, and they equate spiritual awakening with a EMRICK, C. (1993). Efﬁcacy of Alcoholics Anonymous: A realignment of personal goals, speciﬁcally a move- meta-analysis of research. In B.S. McCrady & W.R. ment away from radical individualism and the pur- Miller (Eds.), Research on Alcoholics Anonymous: suit of the material, toward community and the Opportunities and alternatives. New Brunswick, NJ: pursuit of serenity as core values. Rutgers Center of Alcohol Studies. The twelfth step of AA states: ‘‘Having had a FIORENTINE, R. (1999). After drug treatment: Are spiritual awakening as the result off these steps, we 12-step programs effective in maintaining absti- TREATMENT TYPES: An Overview 1215

nence? American Journal of Drug and Alcohol Abuse, should allow the reader to become reasonably fa- 25 (1): 93–116. miliar with what is considered mainstream treat- FOWLER, J. (1993). Alcoholics Anonymous and faith de- ment in the United States today. velopment. In B. S. McCrady & W.R. Miller (Eds.), This section contains the following articles: An Research on Alcoholics Anonymous: Opportunities Overview; Acupuncture; Approaches based on Be- and alternatives. New Brunswick, NJ: Rutgers Center havioral Principles; Aversion Therapy; Behavior of Alcohol Studies. Modification; Cognitive Therapy; Contingency NOWINSKI,J.&BAKER, S. (1998). The twelve-step facili- Management; Family Therapy; Group Therapy; tation handbook: A systematic approach to early re- Hypnosis; Long-Term versus Brief; Minnesota covery from alcoholism and addiction. San Francisco: Model; Nonmedical Detoxification; Outpatient ver- Jossey-Bass. sus Inpatient; Pharmacotherapy, An Overview; NOWINSKI, J., BAKER, S., & CARROLL, K. (1992). Twelve- Psychological Approaches; Self-Help and Anony- step facilitation therapy manual: A clinical research mous Groups; Therapeutic Communities; Tradi- guide for therapists treating individuals with alcohol tional Dynamic Psychotherapy; and Twelve Steps, abuse and dependence. DHHS Publication Mo. ADM The. 92-1893, Project MATCH Monograph Series, Vol. 1. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. An Overview According to the 1998 Na- PROJECT MATCH RESEARCH GROUP (1997). Matching al- tional Household Survey on Drug Abuse, of the coholism treatments to client heterogeneity; Project 23.1 million Americans who used an illicit drug in MATCH Posttreatment drinking outcomes. Journal of the past year, 1.9 million reported some health Studies on Alcoholism, 58, 7–29. problem due to their illicit drug use, 3.5 million SERAGANIAN, P., BROWN, T. G., TREMBLAY, J., ET AL. reported an emotional or psychological problem (1998). Experimental manipulation of treatment af- due to their drug use, and 4.1 million were depen- tercare regimes for the substance abuser. National dent on an illicit drug. An estimated 963,000 had health research and development program (Canada), received treatment or counseling for their drug use. Project ࠻66O5-4392-404. Concordia University, In addition to those dependent on illicit drugs, an- Montreal, Canada. other 9.7 million Americans are estimated to be JOSEPH NOWINSKI dependent on alcohol, including 915,000 youths age 12-17. Current treatment capacity, including public and private facilities for illicit drug and alcohol treatment, is about 1.7 million treatment TREATMENT TYPES This section pro- episodes a year—clearly short of the need. vides the reader with brief descriptions of some of Prior to referring an addicted patient to treat- the diverse ways that people with substance-related ment, it is important to address certain questions: problems can be helped. Treatment Types presents (1) What are the possible treatment alternatives? descriptions of distinct interventions that are appli- (2) What treatment modalities are best suited for a cable to dependence on each of a variety of drugs. particular patient? (3) What is the efficacy of the In practice, though, treatment programs are hy- preferred treatment? and (4) Is the chosen treat- brids, incorporating features from several distinct ment available to the patient? As will be noted, the treatment modalities and adapting them to specific information base needed to answer these is often needs having to do with age, gender, ethnic, racial, not available. and socioeconomic factors, provider preference, and the economic realities that govern delivery of TREATMENT ALTERNATIVES treatment. Neither this section nor the one above on Treat- Treatment Setting. Excellent treatment can ment is exhaustive. A number of substance depen- be delivered within both outpatient and inpatient dence interventions employed in other countries settings. A more expensive inpatient program does and by certain U.S. ethnic groups (such as sweat not offer the best treatment for all individuals. The lodges among some Native American tribes) are not appropriate placement of a drug-dependent indi- covered. Nevertheless, the entries included here vidual in a treatment program requires the consid- 1216 TREATMENT TYPES: An Overview eration of several factors, including drugs that are issues have often compelled programs to reduce being used, level of psychiatric distress, potential treatment to less than fourteen days. medical complications, family or other support, Outpatient Programs. Outpatient treatment gener- and availability of child care. Intensity of treatment ally consists of drug-free treatment or, in cases of is not necessarily a function of setting since some opiate addiction, methadone treatment. The time outpatient treatment programs provide more infor outpatient drug-free treatment can range from tense treatment than do inpatient ones. once a week to daily daylong activities. In compre- Inpatient Programs. Usually, inpatient settings are hensive treatment programs, individuals may be of three types: (1) detoxification units within medi- initially enrolled in an intensive outpatient pro- cal hospitals, (2) dual-diagnosis programs within gram consisting of many structured daily activities psychiatric hospitals, and (3) rehabilitation pro- (e.g., group therapy, individual therapy, self-help grams. The first two settings are best utilized when groups, educational groups, stress-management there is a risk of serious medical problems (e.g., groups) and ‘‘graduate’’ over a certain period seizures) or psychiatric difficulties (e.g., suicidal (ranging from one to six months) to weekly or ideation). Medical units generally employ pharma- biweekly clinic visits. Random urine testing is usu- cologic detoxification protocols that are based on ally an integral part of these programs. Completion the type of drugs abused and the patient’s concomi- of the intensive portion of the program is usually tant medical condition. The length of stay is usually determined by documented behaviors such as less than two weeks. Although many patients mis- length of abstinence, attendance in groups, and takenly believe that after detoxification no further keeping scheduled appointments. Initiation of intervention is necessary, detoxification is only the change—for example, the avoidance of drug-using beginning of treatment. The next treatment place- friends or the desire to return to work or school— ment should be based on the needs of the patient, may suggest readiness for a less-intensive program. but, unfortunately, it often depends on other fac- Some outpatient programs have the necessary tors (e.g., community resources or the patient’s staff and expertise to provide medically supervised insurance coverage or ability to pay). detoxification. Appropriate patient selection is cru- Dual-diagnosis programs are usually based in cial, however. There has been a growing recogni- psychiatric hospitals and are designed to treat pation that many patients seeking drug treatment tients with both serious psychiatric illnesses and have additional psychiatric disorders (Rounsaville, substance-use disorders. Treatment may include Weissman, & Kleber, 1983; Weiss et al., 1986; individual, group, and family therapy, phar- Rounsaville et al., 1991), and, consequently, psy- macotherapy, relaxation techniques, and educa- chiatrists have been increasingly employed in drug- tion. ALCOHOLICS ANONYMOUS (AA) or NARCOTICS free outpatient settings to both assess patients and, ANONYMOUS (NA) groups may also be offered. Indi- when necessary, provide additional psychiatric viduals may reside in these hospital units from treatment. several weeks to several months. Methadone maintenance programs are designed Rehabilitation units are usually free-standing for patients who have been addicted to opiates for facilities that are often based on the AA TWELVE- at least one year. These patients often have lengthy STEP model of treatment. Some carry out uncom- drug-use histories and have been unable to main- plicated pharmacologic detoxifications, but many tain abstinence after repeated detoxifications. Veri- patients are already detoxified at entry. Some reha- fication of opiate addiction may be determined by bilitation programs are staffed to offer psychiatric using a naloxone challenge test or by observing evaluation or treatment (or both). Therapy usually withdrawal symptoms. Because of the risk of trans- consists of education, group therapy, individual mitting the human immunodeficiency virus (HIV), meetings, and at times, specialized groups (e.g., a pregnant and HIV-positive opiate-dependent indi- women’s group), usually provided by drug or alco- viduals may be given admission priority in some hol counselors. Social workers may provide family programs. As is the case with drug-free treatment therapy. Traditionally, the standard length of stay programs, methadone programs vary in the com- was twenty-eight days, but lack of data to support prehensiveness of their services. Some additional the advantages of this length and reimbursement psychosocial services provided by a methadone TREATMENT TYPES: An Overview 1217 program may include the teaching of job-hunting sensations related to the drug itself, (2) the avoid- skills, family therapy, and parenting groups. ance of actual or conditioned withdrawal symp- Residential Programs. Residential programs can be toms, (3) the perceived reduction of distressing used as a bridge between inpatient and outpatient psychologic symptoms, (4) the fear of losing a so- programs or as an alternative to them. Intermedi- cial network centered on drug use, and (5) the ate-care facilities, similar to those developed at HA- anxiety associated with having to confront painful ZEL-DEN, allow individuals to live within a residen- issues once drug use ceases. tial setting, be employed during the day, and Several clinicians have attempted to counter receive comprehensive treatment, including group drug-promoting reinforcers with other reinforcers therapy, individual counseling and monitoring, that were contingent on non—drug taking behav- and education. Both behavioral models and the ior. Higgins et al. (1993) developed a voucher sys- principles of Alcoholics Anonymous are applied. tem in which negative urine screens were rewarded The average stay is approximately four months. with vouchers that could be used to purchase a THERAPEUTIC COMMUNITIES provide treatment variety of community-based items viewed as within highly structured, hierarchical residential prosocial and consistent with a drug-free lifestyle. settings that stress the importance of community When compared to a control group that had re- and recovering staff in treatment. More recently, ceived standard drug counseling, it was found that professionals with or without prior drug histories the behavioral group remained in treatment longer are providing managerial expertise and treatment. and had more discrete periods of abstinence. Within therapeutic communities, behavior is Operant techniques can be applied in various shaped by using rewards and penalties (Kleber, treatment settings by using fairly simple yet effec- 1989). Drug abusers are constantly confronted by tive reinforcers. For example, methadone programs their peers in a variety of situations regarding their may offer drug abusers take-home doses for nega- functioning within the program. Jobs range from tive urine results. Because compliance is more low to high status and are allocated to individuals likely to occur if the positive reinforcement is tem- on the basis of the length of their stay in the com- porally linked with the desired behavior, take- munity, their competence, and their ability to home doses immediately offered after two weeks of behave responsibly. Traditional therapeutic com- negative urine tests work better than if the take- munities recommend stays of twelve to twenty-four months whereas newer programs are experiment- home doses are delayed until a prolonged period of ing with stays of three to six months. abstinence has been accomplished. CONTINGENCY Treatment Modalities. Treatment interven- MANAGEMENT and respondent conditioning are two tions can be categorized in terms of behavioral, alternative behavioral interventions that are occa- self-help, psychological, or pharmacological ap- sionally used for treating substance abuse. Contin- proaches. Although a specific treatment setting gency contracting applies negative contingencies to may emphasize one type of intervention, additional undesirable behavior. For example, patients who modalities are often employed. Generally, pro- are concealing their drug use from their bosses, grams proficient in using diverse treatment meth- family members, or anyone else may be asked to ods are more likely to change their therapeutic in- sign a ‘‘contract’’ that allows their therapist to interventions if the initial approaches appear form one or more specific individuals if their drug ineffective. use resumes. Behavioral Approaches. Various behavioral treat- Respondent conditioning may involve the use of ments, using the psychological theories of operant noxious stimuli. For example, individuals may be and respondent conditioning, have been designed given a chemical that induces nausea (e.g., apo- to treat substance abuse. Experimental psycholo- morphine) while receiving an injection of their drug gists found that behavior could be shaped if posi- of choice or while handling drug-related parapher- tive consequences occurred as a result of the nalia. The drug may come to induce unpleasant changed behavior. Used with drug abusers, operant feelings as a result of its association with the nox- conditioning is complicated since many positive ious stimuli. Poor patient acceptance, ethical is- and negative reinforcers may promote continued sues, and insufficient data regarding efficacy limit drug use. These reinforcers include: (1) the positive the use of these AVERSIVE TREATMENT approaches. 1218 TREATMENT TYPES: An Overview

Self-Help Approaches. These interventions have tion) such that it does not degenerate into a ‘‘re- evolved from the personal experiences and ideas lapse’’ (i.e., problem use). generated by Bob Smith and Bill Wilson, two alco- The final stages, late recovery and maintenance, holics who cofounded Alcoholics Anonymous. The emphasize personal growth in areas such as self- organization has grown until, in 2000, it estimated esteem, spirituality, intimacy, and work while indi- that it numbers more than 99,000 groups world- viduals are maintaining a drug-free lifestyle. When wide. Although AA’s approach to gaining SOBRIETY there are deficits in these areas, insight-oriented (the Twelve Steps) and its principles (the Twelve therapy may be helpful. The reasons for continued Traditions) are commonly integrated into many inadequate functioning can be extremely complex treatment programs, it remains unclear which pa- and may involve unresolved issues from childhood. tients benefit most from self-help programs, partic- Kaufman and Redoux (1988) emphasized that un- ularly when they are used without other interven- covering core conflicts and confronting maladap- tions. The concepts of AA have also been applied to tive defenses might elicit intense anxiety. Unless other psychoactive-substance use disorders (e.g., in patients were in the late recovery stage, they might the programs of COCAINE ANONYMOUS and Narcot- revert to their former maladaptive mode of ics Anonymous). coping—namely, using drugs. Psychological Approaches. Psychological ap- The developmental model should be used as a proaches are used to try to understand the psycho- guideline in understanding the recovery process logical or cognitive issues that promote drug use rather than as a paradigm that is directly applica- and, with this knowledge, to provide appropriate ble to all patients. Additionally, there may be ex- treatment interventions. As Zweben (1986) em- ceptions to when certain psychological interven- phasized, the goals of recovery-oriented psycho- tions should be utilized. For example, an individual therapy change as addicted individuals progress in with major depression might not benefit from re- their recovery. The manner in which recovery lapse-prevention techniques until the depression ‘‘progresses’’ has been clearly conceptualized by has been treated. Pharmacologic Approaches. Gorski and Miller (1986) in their six-stage develop- Medications can serve as useful adjuncts in a com- mental model. Each of the stages has a primary prehensive treatment plan. The appropriate use of goal, and different types of psychological interven- these agents depends on the patient’s medical and tions become appropriate, depending on the goal. During the first two phases, pretreatment and psychiatric status, prior treatment experience, and stabilization, the focus is placed on challenging the the clinical setting. Generally, the novel as well as denial of patients regarding the consequences of established pharmacotherapies can be put into four their disease and, subsequently, on addressing the classifications: (1) AGONISTS,(2)ANTAGONISTS, symptoms of acute and post-acute withdrawal. For (3) antiwithdrawal agents, and (4) anticraving therapists to engage patients into treatment, they agents. need to be skillful at both confrontational and sup- Agonists bind and activate receptors on cell portive approaches. During the third and fourth membranes, and these operations then lead to a stages of early and middle recovery, the patients’ cascade of biologic activities. Drugs themselves are major goals are to learn to function without drugs usually agonists and may generate strong physio- or alcohol and to develop a healthy lifestyle. For logic responses (i.e., full agonists) or weak re- these stages, a cognitive approach focused on Re- sponses (i.e., partial agonists). The use of a specific lapse Prevention is useful. Marlatt and Gordon agonist is limited to treatment of abuse of a drug (1985) stressed that drug relapse was often due to from the same pharmacological class. Agonists are ineffective coping with high-risk situations. Al- generally used for detoxification or for medication though individuals have their own unique list of maintenance, and, when chosen for these purposes, high-risk situations, the situations are usually re- they are likely to be well absorbed orally and slowly lated to interpersonal conflicts, social pressure, eliminated from the body. Slowly metabolized conditioned cues, or negative emotional states. The medications are less likely to produce a severe with- therapeutic work of this approach is to develop drawal syndrome but are more likely to produce a effective coping responses as well as learn to handle protracted, albeit less intense, one. Because ago- a ‘‘lapse’’ (i.e., a single drink or drug administra- nists induce positive drug effects, they are well ac- TREATMENT TYPES: An Overview 1219 cepted. This, however, also means that they have Agents used for opiate detoxification include meth- the potential for abuse. adone, CLONIDINE, and lofexidine; although effec- The most commonly used agonist for both main- tive for opiate detoxification, the latter two have not tenance and for opiate withdrawal is methadone, received FDA approval for this indication. The use which itself is an opiate. BUPRENORPHINE, a partial of the dopamine agonists bromocriptine and AM- opioid agonist, is being evaluated in the mid-1990s ANTADINE have been suggested for the manifesta- and may have less potential for abuse and be asso- tions of cocaine withdrawal, but their efficacy re- ciated with fewer withdrawal symptoms than mains unclear. The most appropriate methadone when used for opiate detoxification. antiwithdrawal regimen for a particular clinical L-ALPHA-ACETYLMETHADOL (LAAM), also an opi- situation is not always the one chosen. This situa- ate drug, has recently (1993) received FDA ap- tion may be due to federal and state regulations, proval for use in treating opiate abuse. Unlike physician or patient bias, reimbursement issues, methadone, which must be taken daily, LAAM can and the lack of available expertise within a commu- be given three times a week, thereby decreasing the nity in the use of particular methods (Kleber, number of clinic visits for the patient as well as the 1994). risk of medication diversion. Few agonist drugs The development of anticraving agents to treat have been developed for other types of drug abuse, drug dependence is a new treatment strategy. Ear- although NICOTINE, delivered transdermally, is be- lier conceptualizations of craving focused on the ing used with some success to treat tobacco depen- physical aspects (i.e., the individual ‘‘craved’’ the dence. drug because he or she was experiencing physical Antagonists prevent agonists (i.e., the abused withdrawal symptoms). Thus the emphasis was drug) from producing their full physiologic replaced on developing antiwithdrawal rather than sponse, either by blocking the receptor site or by anticraving drugs. During the last decade, as co- disrupting the functioning of the receptor. Short- caine use soared, clinicians noted that craving acting antagonists are most commonly used for could be psychologically based and be a significant treatment of acute intoxication or overdose and relapse trigger (Gawin & Kleber, 1986). Much re- long-acting ones for rapid detoxification and research was consequently done to find useful an- lapse prevention. The benefits of antagonists are ticraving medications. Although desipramine re- that they produce no euphorigenic effect, have no mains promising, no medication has been potential for abuse, and produce no withdrawal unequivocally shown to be an effective anticraving syndrome. Although generally only antagonists agent for cocaine addiction. that block the specific receptor activated by the specific drug can be used for drug-abuse treatment, research is suggesting that the opiate antagonist ASSESSMENT OF NALTREXONE may play a role in diminishing alco- TREATMENT OUTCOME hol drinking after a single drink. Although treatment for substance abuse can Commonly used opioid antagonists include nal- work, which treatment setting or modality will oxone and naltrexone. Naloxone reverses the respi- work best for each patient cannot invariably be ratory depression associated with opiate overdoses. predicted. Using a number of outcome studies, re- Naltrexone is used after detoxification to maintain searchers at the Institute of Medicine (Gerstein & abstinence. Unfortunately, relatively few patients Harwood, 1990) reached several conclusions re- take an antagonist as prescribed because of its lack garding the efficacy of various treatment modali- of pleasant effect, its lack of effect on withdrawal if ties: the patient ceases taking the medication, and at times the persistence of craving (Kleber, 1989). 1. Methadone Programs Opiate-dependent indi- Development of a monthly, long-acting injectable viduals maintained on methadone exhibit less formulation may soon increase compliance when it illicit drug use and other criminal behavior than reaches the market. do individuals discharged after being in the pro- Antiwithdrawal medications are given to mini- gram for a period of time or not treated at all. mize the discomfort associated with detoxification For opiate-dependent individuals, there are from drugs that induce physiologic dependence. higher retention rates in methadone programs 1220 TREATMENT TYPES: An Overview

as compared to other programs, and patients Using this instrument, McLellan et al. (1984) tend to do better if they are stabilized at higher found that opiate-addicted patients with severe doses. Problems include continued use of psychological problems did worse over time when nonopiate drugs, especially cocaine, and diffi- placed in a therapeutic community compared to culty withdrawing. those placed in methadone programs. As this study 2. Therapeutic Communities The length of stay illustrates, it is critically important to assess within these communities, even for those who do ‘‘nondrug’’ variables when evaluating treatment not complete the program, is the best predictor response, and to carry out a comprehensive assess- of treatment outcome measured by drug use, ment prior to, during, and after treatment. criminal behavior, and social functioning. In the past few years, there has been greater Graduates from therapeutic communities have emphasis on understanding how the specific as- superior outcomes when compared to dropouts. pects of treatment programs (e.g., therapeutic skills Dropout rates are unfortunately as high as 75 of the counselors, treatment modalities used, psy- percent, although data suggest that even those chosocial services offered) influence treatment out- who do not graduate derive some benefit if they come. In regard to treatment services, McLellan et have stayed for a period of time. al. (1992) developed a rapid interview, the Treat- 3. Outpatient Nonmethadone Programs As with ment Services Review (TSR), which provides an individuals in therapeutic communities, indi- evaluation of the amount and type of psychosocial viduals who graduate from these programs have services provided to patients during treatment. The better outcomes than those who drop out, and investigators have suggested that this type of re- individuals who enter the programs have better view might be useful when comparing different outcomes than those who were contacted but programs or for determining if the needs of individ- did not begin the programs. These programs ual patients were met during treatment. A recent tended to treat less severely dependent patients. study by McLellan et al. (1993) found that metha- 4. Chemical Dependency Programs There were in- done-maintained patients who received enhanced adequate data to evaluate the efficacy of resi- psychosocial services did significantly better than dential or inpatient programs (so-called 28-day those who received standard or minimal services. MINNESOTA MODEL programs) designed to treat No single study, no matter how comprehensive, drug problems, and there were no data regard- can address all of the factors that influence treating whether hospital or free-standing programs ment outcome. Instead, studies will need to focus were more effective. on specific subpopulations of patients when com- Hubbard (1992) found that individuals referred paring various treatment interventions as well as from the criminal justice system performed as well the impact on treatment of factors often overlooked in treatment as did other patients entering without (e.g., the patient’s stage of recovery and the extent such pressure, and that drug-abuse treatment proof program hours). vides a favorable cost-benefit ratio to society within one year of completion of treatment. RECOMMENDED TREATMENT Recognizing that treatment success is multifac- POLICIES torial, investigators have sought comprehensive yet Since many Americans are still in need of treat- practical ways to characterize both patients and ment for drug abuse problems, rational treatment treatment programs. One instrument increasingly policies need to be established on the basis of our used to assess patient functioning is the ADDICTION current knowledge regarding the extent of the SEVERITY INDEX (ASI) (McLellan et al., 1980). problem and what interventions work. Such poli- Using the ASI, the interviewer rates the severity of cies should address the following issues (Kleber, the patient’s problem across six domains: alcohol 1993): and drug use, medical status, employment and support status, family and social relationships, legal 1. Available treatment needs to be expanded. Al- status, psychiatric status. By giving the ASI at ad- though there are approximately 6 million indi- mission and repeating it over time, treatment suc- viduals in need of drug treatment, the current cess can be assessed in a standardized manner. system can treat less than 2 million a year. TREATMENT TYPES: An Overview 1221

2. Patients need to have access to a wide variety of drug abusers in appropriate, well-organized treat- treatment modalities. Since no one treatment is ment systems?’’ If these issues are successfully ad- suitable for all patients, a community with a dressed, treatment strategies can be designed for diversity of treatment services can more likely each patient and yet remain affordable. Millions offer appropriate interventions to its popula- spent on effective treatment will save billions spent tion. elsewhere. 3. For treatment improvement to occur, there must be more funds dedicated to research along with (SEE ALSO: Abuse Liability of Drugs; Coerced efficient dissemination of new technologies. Treatment for Substance Offenders; Comorbidity Without new research, progress will not be and Vulnerability; Research; Substance Abuse and achieved. Without training and education of AIDS; Treatment; Treatment in the Federal Prison staff regarding new research findings, treatment System) will not improve. 4. Pressure must be exerted to encourage drug- BIBLIOGRAPHY addicted individuals to enter treatment. As noted earlier, those who enter under pressure DODGEN, C. E., & SHEA, W. M.(2000). Substance use from the criminal justice system do as well as disorders: Assessment and treatment. San Diego, CA: those entering voluntarily. The family, em- Academic Press. ployer, or criminal justice system can all be in- GAWIN, F. H., & KLEBER, H. D. (1986). Abstinence strumental in getting individuals to enter and symptomatology and psychiatric diagnosis in cocaine remain in treatment. This pressure must be sus- abusers: Clinical observations. Archives of General tained since when it remits, the individual often Psychiatry, 43, 107–113. drops out of treatment. GERSTEIN, D. R., & HARWOOD, H. J. (1990). Summary- 5. The treatment needs of special populations Treating Drug Problems: A study of the evolution, (e.g., prisoners, pregnant women, HIV-infected effectiveness, and financing of public and private drug individuals) require greater attention. There are treatment systems, Vol. 1. Institute of Medicine, Com- few programs designed to treat drug-addicted mittee for the Substance Abuse Coverage Study Divi- prisoners while they are incarcerated or newly sion of Health Care Services. Washington, DC: Na- released. For pregnant drug abusers to engage tional Academy Press. in treatment, programs need to be accessible, be GORSKI, T., & MILLER, M. (1986). Staying sober: A guide affordable, include child care (for optimal re- for relapse prevention. Independence, MO: Indepen- sults), and reflect a nonjudgmental view. For dence Press. HIV-infected individuals, comprehensive medi- HIGGINS, S. T., ET AL. (1993). Achieving cocaine absti- cal care should be linked with the substance- nence with a behavioral approach. American Journal abuse treatment, especially considering the ris- of Psychiatry, 150, 763–769. ing incidence of tuberculosis in this group. HUBBARD, R. L. (1997). Evaluation and treatment out- 6. Rehabilitation and habilitation need to be inte- come. In J. H. Lowinson et al. (Eds.), Substance grated into substance-abuse treatment pro- abuse: A comprehensive textbook (3rd ed.). Balti- grams. Some drug-dependent individuals have more: Lippincott Williams & Wilkins. the educational background or skills that allow KAUFMAN, E., & REDOUX, J. (1988). Guidelines for the them to gain employment once their drug prob- successful psychotherapy of substance abusers. Amer- lem has been treated. Others may require job- ican Journal of Drug Alcohol Abuse, 14, 199–209. seeking skills, job training, or additional school- KLEBER, H. D. (1994). Detoxification from opioid drugs. ing prior to seeking employment. A goal of treat- In M. Galanter & H. D. Kleber (Eds.), The American ment needs to be integration into society, not Psychiatric Press Textbook of Substance Abuse simply cessation of drug use. Treatment. Washington, DC: American Psychiatric Press. When examining the different modalities of KLEBER, H. D. (1993). America’s drug strategy: Lessons treatment the question is not, ‘‘Does treatment of the past . . . steps toward the future. Paper pre- work?’’ but rather, ‘‘What works best for a particu- sented at a Senate Judiciary Committee Hearing, lar individual?’’ and ‘‘What can be done to engage April, Washington, DC. 1222 TREATMENT TYPES: Acupuncture

KLEBER, H. D. (1989). Treatment of drug dependence: WEISS,R.D.,ET AL. (1986). Psychopathology in chronic What works. International Review of Psychiatry, 1, cocaine abusers. American Journal of Alcohol Abuse, 81–100. 12, 17–29. KOSTEN, T. R., & STINE,S.M.(EDS.). (1997). New treat- ZWEBEN, J. E. (1986). Recovery oriented psychotherapy. ments for opioid dependence. New York: Guilford Journal of Substance Abuse Treatment, 3, 255–262. Press. FRANCES R. LEVIN KRANZLER, H. R. (2000). Medications for alcohol depen- HERBERT D.KLEBER dence-new vistas. Journal of the American Medical REVISEDBY ANNE DAVIDSON Association, 280, 1016–1017. MARLATT, G. A., & GORDON, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of Acupuncture The art of acupuncture is an addictive behaviors. New York: Guilford Press. ancient and integral part of the armamentarium MARWICK, C. (1998). Study: Treatment works for sub- used in China for the treatment of medical prob- stance abusers. Journal of the American Medical Asso- lems. Acupuncture consists of the insertion of very ciation, 280, 1126–1127. fine needles into the skin at specific points in- MCCANCE-KATZ, E. F., & KOSTEN,T.R.(EDS.). (1998). tended, according to traditional Chinese medicine, New treatments for chemical addictions. Washington, to influence specific body functions or body parts. DC: American Psychiatric Press Press. In the traditional Chinese view of the body, life MCLELLAN, A. T., ET AL. (1993). The effects of psychoso- energy, (chi), circulates through pathways; block- cial services in substance abuse treatment. Journal of age of the pathways leads to deficiency of chi,or the American Medical Association, 269, 1953–1959. disease. The goal of the traditional acupuncturist is MCLELLAN, A. T., ET AL. (1992). A new measure of sub- to open up the pathways and stimulate the move- stance abuse treatment: Initial studies of the treatment of chi. The specific points for needle insertion ment services review. Journal of Nervous and Mental are based on traditional anatomy maps that depict Disease, 180, 101–110. which pathways affect which body functions. MCLELLAN, A. T., ET AL. (1984). The psychiatrically se- Following President Richard M. Nixon’s historic vere drug abuse patient: Methadone maintenance or trip to China in 1972, considerable public interest therapeutic community? American Journal of Drug & in acupuncture was generated when the media ob- Alcohol Abuse, 10, 77–95. served that acupuncture was not only effective in MCLELLAN, A. T., ET AL. (1980). An improved diagnostic relieving pain, but could also be a substitute for instrument for substance abuse patients: The Addic- general anesthesia. The following year, Dr. H. L. tion Severity Index. Journal of Nervous and Mental Wen, a neurosurgeon in Hong Kong, reported a Disease, 168, 26–33. serendipitous observation that acupuncture with NACE, E. P. (1997). Alcoholics anonymous. In J. H. electrical stimulation (AES) eliminated withdrawal Lowinson et al. (Eds.), Substance abuse: A compre- symptoms in a narcotics addict on whom he had hensive textbook (3rd ed.). Baltimore: Lippincott intended to perform brain surgery to treat drug Williams & Wilkins. addiction. The discovery occurred the day before ROTGERS, F., ET AL.(EDS.). (1996). Treating substance the scheduled surgery while Dr. Wen was demon- abuse: Theory and technique. New York: Guilford strating to the patient that AES could relieve pain. Press. Fifteen minutes after the AES had begun, the pa- ROUNSAVILLE, B. J., & KOSTEN, T. R. (2000). Treatment tient reported a significant reduction of his drug for opioid dependence: Quality and access. Journal of withdrawal symptoms, which disappeared alto- the American Medical Association, 283, 1337–1339. gether thirty minutes after AES was started. Dr. ROUNSAVILLE, B. J., WEISSMAN, M. M., & KLEBER,H.D. Wen followed this patient, noting that AES had to (1983). An evaluation of depression in opiate addicts. be administered every eight hours for the first three Research in Community and Mental Health, 3, 257– days, and gradually the intervals could be in- 289. creased. Within a week there were no further signs ROUNSAVILLE, B. J., ET AL. (1991). Psychiatric diagnoses or symptoms of withdrawal. This led Dr. Wen to of treatment-seeking cocaine abusers. Archives of conduct a study of AES in 40 narcotics addicts General Psychiatry, 48, 43–51. experiencing withdrawal. All but one (who re- TREATMENT TYPES: Acupuncture 1223

CNS; withdrawal symptoms occur when these drugs are abruptly discontinued. Since the administration of opioid drugs alleviates withdrawal, it was reasonable to believe that one’s own endogenous opioids might do the same. During the mid-1970s, the use of acupuncture became popular in the United States, despite the absence of the kind of rigorous clinical investigation typically required for new pharmacological treatments. There were probably a number of factors that contributed to its popularity. Because it involved no pharmacological agents, it was seen as being more compatible with the approach espoused by SELF-HELP groups, ranging from ALCOHOLICS ANONYMOUS (AA) to THERAPEUTIC COMMUNITIES. Also, acupuncture did not initially require medical personnel, so it was relatively inexpensive compared to either psychotherapy or pharmacotherapy. In addition, its popularity increased at a time when some people objected to using METHADONE for drug detoxification or for maintenance, on the grounds that such use made drug- dependent minority-group members dependent upon the medical establishment. A technique from a non-Western tradition seemed, therefore, to have special appeal for treatment programs that dealt predominantly with minorities. One such program was the Division of Substance The use of acupuncture in addiction treatment is Abuse at Lincoln Hospital in the south Bronx, New popular, despite the absence of clear evidence York, under the leadership of Dr. Michael O. that it is an effective treatment for opiate or Smith. Smith was interested in alternatives to cocaine dependence. (᭧ Roger Ressmeyer/CORBIS) methadone for detoxification. Based on Wen’s work, Smith first used electrical stimulation along quired medication for severe pain and was dropped with acupuncture, but he later discarded the use of from the study) were successfully detoxified. It is electrical stimulation. Eventually, a standard pro- noteworthy that Dr. Wen’s initial observations oc- tocol was developed which used four or five acu- curred prior to the discovery, in 1975, of endoge- puncture points on each ear. By 1975, the use of nous opioid substances in the brain (also called acupuncture as a treatment for drug abuse was endorphins). extended to alcohol patients, then later to cocaine In a later study, in 1977, Dr. Wen noted that and crack-cocaine patients. AES increased endorphin levels and relieved absti- In 1985 Smith founded the National Acupunc- nence syndromes while simultaneously inhibiting ture Detoxification Association (NADA) at 3115 the autonomic nervous system, primarily the para- Broadway, ࠻51, New York, New York 10027. By sympathetic nervous system. The findings by Dr. 1993, when the second international conference of Wen and several other scientific groups that pe- NADA was held in Budapest, Hungary, there were ripheral stimulation could release endogenous opi- participants from all over the world. oid substances in the central nervous system (CNS) In the early 1990s, the use of acupuncture in gave scientific credibility to the possibility that this addiction treatment had become popular with traditional Chinese therapy could help to deal with many people working in the criminal-justice sys- a contemporary problem. Chronic or repeated ex- tem. Most of the funding for treatment programs posure to opioids leads to adaptive changes in the using acupuncture at that time came initially from 1224 TREATMENT TYPES: Acupuncture the criminal-justice system, rather than from the pants, Dr. George Ulett, noted that although there federal and state agencies that usually fund drug is some evidence that electrical stimulation through treatment programs. Although the scientific com- needles or electrodes placed at certain points on the munity had been unable to show the efficacy of body can release endogenous opioids and other acupuncture in properly controlled clinical studies, neuropeptides in the central nervous system, there this relatively inexpensive and easily expanded pro- is little evidence that such release is caused by nee- cedure became the mainstay of a number of ‘‘drug dles alone. He also asserted that the critical factor is courts,’’ where judges involved themselves directly the frequency characteristic of the current, not the in managing the treatment of drug offenders. specific placement site of needles or electrodes. This At many clinics in the United States, acupunc- group of researchers concluded that part of the ture treatment is now offered as part of a broad difficulty in deciding whether acupuncture is effec- psychosocial program that has elements of self-help tive was the lack of standard terminology and stan- and TWELVE-STEP programs, plus traditional med- dard methods. A number of procedures, all called icine and alternative medicine (some clinics, for ex- acupuncture, were being applied to a variety of ample, use a ‘‘sleep mix’’ tea brewed from a variety drug and alcohol problems, but in different ways, of herbs). over varying periods of time, with results measured As practiced in the United States, several techni- in differing ways. For example, different numbers cal procedures broadly described as acupuncture of acupuncture needles could be used, at different have been used. Standard bilateral acupuncture is sites, with or without electrical current. One study the application of five needles to the concha and of acupuncture for alcohol detoxification, by Bul- cartilage ridge of each ear at defined points (shen lock and coworkers, which came closest to being men, lung, sympathetic, kidney, and liver) deter- scientifically valid, used appropriate controls mined from traditional Chinese anatomy maps. (placement of needles in non-sites) and staff who With unilateral acupuncture, the needles are ap- were ‘‘blinded’’ as to which group was control and plied to one ear. Acupressure involves applying which was receiving acupuncture at specific body pressure by hand or by an object to the same areas. sites. This study found a far better outcome for Electroacupuncture applies low level electric cur- patients in the specific body-site group than for rent to needles placed at the traditional points. controls—and that the difference persisted even With moxibustion, herbs are burned near the nee- when measured six months later. However, another dles to add heat; and with neuroelectric stimula- research group using similar methodology could tion, low dose electrical current is passed through not replicate the findings and reported no differ- surface electrodes. Some practitioners advocate the ence between point-specific acupuncture, sham use of surface electrodes and special currents, des- transdermal stimulation, or standard care (no acu- ignating this approach neuroelectrical therapy puncture control). (NET). There is no more evidence for the efficacy of Many practitioners who have used acupuncture, added electrical current in the acupuncture treat- even those who are convinced of its efficacy, report ment of drug and alcohol problems than there is for that only a small proportion of people who start acupuncture itself. treatment actually complete the typical series of ten Many acupuncture practitioners in the United to twenty treatments. Those who have used the States belong to and are accredited by the Ameri- technique believe that the minimal amount of can Association of Acupuncture and Oriental Medi- treatment required for benefit is at least one cine (AAAOM), founded in 1981. Others may be twenty-minute session per day of bilateral acu- accredited by the National Acupuncture and Orien- puncture for at least ten days. In general, among tal Medicine Alliance (NAOMA), founded in 1992, both opioid-dependent and cocaine-dependent pa- which accepts a broader range of training for pur- tients, those with lighter habits seemed to fare best. poses of certification than AAAOM. The NIDA technical review panel concluded In 1991, the NATIONAL INSTITUTE ON DRUG that, at the time of the review (1991), there was no ABUSE (NIDA) sponsored a technical review of the compelling evidence that acupuncture is an effec- current state of knowledge about the use of acu- tive treatment for opiate or cocaine dependence. puncture in the treatment of alcoholism and other Nevertheless, they found no evidence that acupunc- drug-dependence problems. One of the partici- ture is harmful. TREATMENT TYPES: Approaches Based on Behavior Principles 1225

BIBLIOGRAPHY mental, social and interpersonal antecedents and consequences of their drug use. For example, if BRUMBAUGH, A. G. (1993). Acupuncture: New perspec- drug use or problematic use is more likely when tives in chemical dependency treatment. Journal of patients are in a particular setting (e.g., bars) or the Substance Abuse Treatment, 10, 35–43. company of certain individuals (e.g., former high- MCLELLAN, A. T., ET AL. (1993). Acupuncture treatment school buddies), they are counseled to restructure for drug abuse: A technical review. Journal of Sub- their environment to avoid or minimize contact stance Abuse Treatment, 10, 569–576. with those settings or people. Sometimes the goal JOYCE H. LOWINSON might be to alter the setting in which the patient JEROME H. JAFFE socializes with a particular individual (e.g., get together with a particular friend at a sporting event rather than a bar). Regarding consequences, the Approaches Based on Behavior Princi- individual is counseled to make explicit the nega- ples Behavioral treatments are based on a model tive consequences of drug use and to identify of drug dependence wherein drug use is considered healthy alternatives to the positive consequences a learned behavior that is directly influenced by derived from drug use and intoxication. antecedent and consequent events associated with Patients often receive coping skills training in drug use. Within this framework, drug use is areas deemed important to discontinuing drug use deemed the primary target of assessment and treat- and avoiding relapse. To combat the common ment. The treatments are generally directed toward problem of social pressure to use drugs, for exam- a goal of complete abstinence from drug use when ple, patients are systematically instructed in drug- dealing with dependent individuals, but mod- refusal skills through role-playing and other exer- eration is an acceptable goal when dealing with cises. Other aspects of social skills training and non-dependent individuals who engage in prob- problem solving are also commonly included in be- lematic use (e.g., drinking and driving). Many of havioral treatments for drug dependence (Monti et the treatments also focus on the promotion of al., 1995). When moderation is the goal with prob- prosocial behaviors that are incompatible with con- lem drinkers, individuals are taught to monitor tinuing the lifestyle of a drug abuser. their drinking, set ingestion limits, and to use spe- Three well-known behavioral treatments are cific strategies to limit the amount consumed (e.g., covered in this section (for more comprehensive do not drink alcoholic beverages to quench thirst, reviews regarding behavioral treatments for alco- take small sips, alternate between alcoholic and hol dependence, illicit drug dependence, and nic- nonalcoholic drinks) (Hester, 1995). otine dependence, see Hester & Miller, 1995; A relatively extensive scientific literature sup- Stitzer & Higgins, 1995; U.S. Department of ports the efficacy of behavioral treatments for vari- Health and Human Services, 1996, respectively). ous forms of drug dependence and problematic use. Each of these treatments has been demonstrated to For example, a series of clinical trials have demon- be efficacious in controlled studies. Contingency strated that social skills training is an efficacious management is another prominent behavioral adjunct treatment for alcohol dependence (Miller at treatment for drug dependence, but is covered in a al., 1995; Monti et al., 1995). Most of these studies separate section of this volume. Other important have examined the effectiveness of social skills learning-based treatments, such as brief interven- training as an adjunct to other treatments, and tions, motivational interviewing, and relapse pre- focused on assertiveness and related social skills. In vention therapy are covered in the Cognitive Be- a seminal study on this topic, for example, forty havioral Treatments section of this volume. adults hospitalized for alcohol dependence were Behavioral Counseling/Skills Training. randomly assigned to either (1) an eight-session Behavioral counseling/skills training emphasizes skills-training group focused on drinking-related environmental restructuring and the acquisition of problem-solving or (2) a control group in which specific skills deemed important to eliminating similar topics were discussed but no specific train- harmful drug use and avoiding relapse. Whether ing was provided. During a one-year follow-up pe- the treatment goal is abstinence or moderation of riod, the skills group compared to the control group harmful use, patients learn how to identify environ- reported an average of fourfold fewer drinks con- 1226 TREATMENT TYPES: Approaches Based on Behavior Principles sumed, sixfold fewer days drunk (eleven versus merit mention. First, couples receive training in sixty-four days during the twelve-month fol- positive communication skills (how to construc- low-up), and a ninefold reduction in duration of tively negotiate for changes in each other’s behav- drinking episodes (average of five days versus ior that will improve the quality of the relationship. forty-four days). Second, when treatment involves disulfiram ther- Although the bulk of the evidence supporting apy for alcohol dependence, spouses are taught the efficacy of social skills training and other how to effectively monitor compliance with the coping skills training has been obtained with alco- medication regimen (Azrin et al., 1982). holics and problem drinkers, evidence is also avail- Multimodal Treatments. Treatment pack- able supporting the efficacy of this approach with ages are sometimes implemented that utilize most individuals who abuse or are dependent on illicit of the adjunct behavioral treatments noted above drugs like cocaine (Monti et al., 1997). as components in a more comprehensive treatment With regard to teaching non-dependent, prob- effort, usually for severely dependent individuals. lem drinkers to moderate their intake, a series of The Community Reinforcement Approach (CRA) is experimental studies reported over a ten-year pe- perhaps the best example of a multimodal-behav- riod indicated that 20 to 70 percent of clinical ioral treatment. CRA includes various forms of so- samples can learn to drink moderately and that cial skills and problem-solving training, vocational those effects can be sustained for up to two years counseling, marital therapy, social/recreational (Hester, 1995). counseling, and socially monitored disulfiram ther- Numerous reviews and meta-analyses support apy (see Meyers & Smith, 1995). the efficacy of behavioral treatments for cessation In the seminal study examining the efficacy of of cigarette smoking (U.S. Department of Health the CRA treatment for alcohol dependence, sixteen and Human Services, 1996). The proportion of pa- males who had been admitted to a state hospital for tients who successfully quit smoking at six- or alcoholism were divided into matched pairs and twelve-month follow-ups generally increases as the randomly assigned to receive CRA plus standard intensity of the intervention increases, with 20 per- hospital care or standard care alone (Hunt & Azrin, cent abstinence rates being common and 40 per- 1973). Following discharge from the hospital, CRA cent being reported in some early studies with inpatients received a tapered schedule of counseling tensive behavioral treatments. Combining behavioral therapy with pharmacological treat- sessions across several months. During a six-month ments (e.g., nicotine gum or patch) generally in- follow-up period, patients who received CRA re- creases quit rates above either intervention alone ported approximately six- to fourteen-fold less time (Hughes, 1995). drinking, unemployed, away from their families, or Behavioral Marital Therapy. Evidence from institutionalized compared to control patients. Sev- studies with alcohol-dependent individuals eral of the CRA elements noted above were added (O’Farrell, 1995) and with individuals dependent in subsequent studies conducted by this same on illicit drugs (Fals-Stewart et al., 1996) indicates group of investigators as the treatment moved from that involving spouses who are not themselves drug being an adjunct to inpatient treatment to a stand- abusers in treatment and providing them with be- alone, comprehensive treatment that could be de- havioral marital therapy can improve the quality of livered in outpatient settings. Findings from these the relationship and drug-use outcomes. The evi- later studies were at least as impressive as in the dence is more robust regarding improvements in seminal study (see Meyers & Smith, 1995). Other marital satisfaction than reductions in drug use, groups have effectively extended CRA to the treat- but both have been documented in controlled stud- ment of opiate (Abbott et al., 1998; Bickel et al., ies. The rationales for involving spouses in treat- 1997) and cocaine dependence (Higgins et al., ment is that they may engage in behavior that 1993, 2000). A contingency management element initiates or reinforces drug use; they can acquire was added in the extension of CRA to the treatment skills that promote abstinence or moderation; and of cocaine dependence (see Budney & Higgins, spouses are an important potential source of alter- 1998) as well as one of the studies on opiate depen- native reinforcement when drug use ceases. Two dence (Bickel et al, 1997), and is discussed in the aspects of behavioral marital therapy particularly section of this volume on contingency management. TREATMENT TYPES: Aversion Therapy 1227

BIBLIOGRAPHY HUNT, G. M., & AZRIN, N. H. (1973). A community-reinforcement approach to alcoholism. Behavior Research ABBOTT, P. J., WELLER, S. B., DELANEY, ET AL. (1998). and Therapy, 11, 91-104. Community reinforcement approach in the treatment MEYERS, R. J., & SMITH, J. E. (1995). Clinical guide to of opiate addicts. American Journal of Drug and Alco- alcohol treatment: the community reinforcement ap- hol Abuse, 24, 17-30. proach. New York: Guilford Press. AZRIN, N. H., SISSON, R. W., MEYERS, R., ET AL. (1982). MILLER, W. R., BROWN, J. M., SIMPSON, ET AL. (1995). Alcoholism treatment by disulﬁram and community Coping and social skills training. In R.K. Hester & reinforcement therapy. Journal of Behavior Therapy W.R. Miller (Eds.) Handbook of alcoholism treatment & Experimental Psychiatry, 13, 105-112. approaches: Effective alternatives, 2nd edition, pp BICKEL, W. K., AMASS, L., HIGGINS, S. T., ET AL. (1997). 12-44. Boston: Allyn and Bacon. Effects of adding behavioral treatment to opioid de- MONTI, P. M., ROHSENOW, D. J., COLBY, S. M., ET AL. toxiﬁcation with buprenorphine. Journal of Consult- (1995). Coping and social skills training. In R.K. ing and Clinical Psychology, 65, 803-810. Hester & W.R. Miller (Eds.) Handbook of alcoholism BUDNEY,A.J.,&HIGGINS, S. T. (1998). The community treatment approaches: Effective alternatives, 2nd edi- reinforcement plus vouchers approach: Manual 2: tion, pp. 221-241. Boston: Allyn and Bacon. National Institute on Drug Abuse therapy manuals for MONTI, P. M., ROHSENOW, D. J., MICHALEC, E., ET AL. ࠻ drug addiction. NIH publication 98-4308. Rock- (1997). Brief coping skills treatment for cocaine ville, MD: National Institute on Drug Abuse. abuse: substance use outcomes at three months. Ad- FALS-STEWART, W., BIRCHLER, G. R., & O’FARRELL diction, 92, 1717-1728. (1996). Behavioral couples therapy for male sub- O’FARRELL, T. J. (1995). Marital and family therapy. In stance abusing patients: Effects on relationship ad- R. K. Hester & W. R. Miller (Eds.) Handbook of alco- justment and drug-using behavior. Journal of Con- holism treatment approaches: Effective alternatives, sulting and Clinical Psychology, 64, 959-972. 2nd edition, pp 195-220. Boston: Allyn and Bacon. HESTER,R.K.,&MILLER, W. R. (1995). Handbook of STITZER,M.L.&HIGGINS, S. T. (1995). Behavioral alcoholism treatment approaches: Effective alterna- treatment of drug and alcohol abuse. In F.E. Bloom & tives, 2nd edition. Boston: Allyn and Bacon. D.J. Kupfer (Eds.), Psychopharmacology: The fourth HESTER, R. K. (1995). Behavioral self-control training. generation of progress (pp. 1807-1819). New York: In R. K. Hester & W. R. Miller (Eds.) Handbook of Raven Press. alcoholism treatment approaches: Effective alterna- U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. tives, 2nd edition, pp 148-159. Boston: Allyn and Smoking cessation: Clinical practice guidelines. Bacon. Washington, DC: US Department of Health and Hu- HIGGINS, S. T., BUDNEY, A. J., BICKEL, ET AL. (1993). man Services, 1996; Agency for Health Care Policy Achieving cocaine abstinence with a behavioral ap- and Research, Research Publication No. 96-0692. proach. American Journal of Psychiatry, 150, 763- STEPHEN T. HIGGINS 769. ALAN J. BUDNEY HIGGINS, S. T., WONG, C. J., BADGER, ET AL. (2000). Con- SARAH HEIL tingent reinforcement increases cocaine abstinence during outpatient treatment and one year of follow-up. Journal of Consulting and Clinical Psychol- Aversion Therapy For many years, at- ogy, 68, 64-72. tempts have been made to condition alcoholics to HUGHES, J. R. (1995). Combining behavioral therapy dislike alcohol. For example, alcoholics are asked and pharmacotherapy for smoking cessation: An up- to taste or smell alcohol just before a date. In L.S. Onken, J.D. Blaine, & J.J. Boren (Eds.), preadministered drug makes them nauseated. Re- Integrating behavioral therapies with medications in peated pairing of alcohol and nausea results in a the treatment of drug dependence: NIDA Research conditioned response—after a while, alcohol alone Monograph 150, pp. 92-109. Rockville, MD: National makes them nauseated. Thereafter, it is hoped, the institute on Drug Abuse. NIH Publication No. smell or taste of alcohol will cause nausea and dis- 95-3899. courage drinking. 1228 TREATMENT TYPES: Aversion Therapy

Instead of pairing alcohol with nausea, other those who didn’t, but another group did better still: therapists have associated it with pain, shocking those who wanted to come back but couldn’t be- patients just after they drink, or they have associ- cause they lived too far from the hospital. All of ated it with panic from not being able to breathe by these people remained abstinent. giving them a drug that causes very brief respira- For many years, chemically induced aversive tory paralysis. Others have trained patients to conditioning of alcoholics was virtually ignored in imagine unpleasant effects from drinking, hoping the literature. Then, in 1990, Smith and Frawley to set up a conditioned response without causing so published an outcome study of patients who re- much physical distress. ceived aversion therapy as part of their inpatient Does it work? Some degree of conditioning is treatment. From a randomly selected sample of usually established, but it is uncertain how long the 200 patients, 80 percent were located and inter- conditioning lasts. The largest study that involved viewed by telephone. Between thirteen and twenty- conditioning alcoholics was conducted many years five months had passed since their discharges from ago in Seattle, Washington (Lemere & Voegtlin, the hospital. The overall abstinence rate for the first 1940). More than 34,000 patients conditioned to twelve months was 71 percent; it was 65 percent for feel nauseated when exposed to alcohol were stud- the total period. ied ten to fifteen years after treatment. Sixty-six Follow-up studies of alcoholism treatment rarely percent were abstinent, an impressive recovery rate report abstinence rates this high. How should these compared to other treatments. The patients who be interpreted? did best had had booster sessions—that is, they had As in the original Seattle study, in the Smith and come back to the clinic after the initial treatment to Frawley study, the patients, by and large, had good repeat the conditioning procedure. Of those who prognostic features. At the time of admission, more attended booster sessions, 90 percent were absti- than 50 percent were married and had some college nent. Based on this study, the nausea treatment for education. Nearly 80 percent were employed. They alcoholism would seem an outstanding success. could afford a private hospital. In short, with char- Why hasn’t it been universally accepted? acteristics that favor a good outcome, they might One reason is that the results can be attributed have done as well without conditioning. Moreover, to factors other than the conditioning. The patients the inpatient program involved more than aversive in the study were a special group. Generally, they conditioning. It included many ingredients found in were well educated, had jobs, and were well off other treatment programs, including counseling, a financially. They may not have received the treat- family program and aftercare plan, and ALCOHOL- ment otherwise, since the clinic where they were ICS ANONYMOUS. treated was private and expensive. Studies of alco- One finding in this report was similar to that of holics have often shown that certain subject char- the original study—booster sessions are important. acteristics are more predictive of successful treat- One month and three months after discharge, the ment outcome than the type of treatment patients were asked to return for reinforcement administered. These factors include job stability, treatments. Just as in the original studies, those living with a relative, absence of a criminal record, who returned for the booster sessions had a partic- and living in a rural community. In the Seattle ularly good outcome. In fact, the most powerful study there was no control group that did not re- predictor of abstinence was the number of rein- ceive conditioning therapy. It is possible that this forcement treatments utilized by each patient. select group of patients, many having characteris- Those taking two reinforcement treatments had a tics that favor a good outcome, would have done as twelve-month abstinence rate of 70 percent; those well without conditioning. who took only one had a 44 percent rate; and those Furthermore, in conditioning treatments, moti- who had no reinforcement had only a 27 percent vation is important. Treatment is voluntary and rate. Seven percent took more than two reinforce- involves acute physical discomfort; presumably few ment treatments and had a phenomenal twelve- would consent to undergo the therapy if they were month abstinence rate of 92 percent. not strongly motivated to stop drinking. The Seat- The importance of reinforcement sessions may tle study makes this point graphically clear. Those reflect motivation on the part of the patient, actual who came back for booster sessions did better than Pavlovian conditioning, or both. The paper does TREATMENT TYPES: Cognitive Therapy 1229

not tell whether the patients developed a true con- matched inpatients from a treatment registry. Alco- ditioned response to alcohol at any time. Informa- hol: Clinical and Experimental Research 5, 862–870. tion about this would help separate nonspecific DONALD W. GOODWIN motivational factors from actual conditioning. The study lacked a control group. This was rem- edied in a report (Smith, Frawley, & Polissar, Cognitive Therapy Cognitive treatment is 1991) that compared 249 alcoholic inpatients who based on the assumption that the way one thinks is received aversion therapy with patients from a na- a primary determinant of feelings and behavior. tional treatment registry who did not receive aver- Developed from Beck’s research (Beck et al., 1979, sion therapy. The patients treated with aversion 1993), cognitive treatment is approached as a col- therapy had significantly higher abstinence rates at laborative effort between the client and therapist to six and twelve months, suggesting that motivation examine the client’s errors and distortions in think- and good prognostic features may not completely ing that contribute to problematic behavior. This explain the success of this still rather unpopular examination is fostered through a combination of treatment. verbal techniques and behavioral experiments to Frawley and Smith (1992) have also reported test the underlying assumptions the client holds remarkably high abstinence rates from cocaine about the problematic behavior. (current abstinence of at least six months, 68 per- Cognitive treatment in the substance-abuse field cent) among a similar group of patients, with good was a direct extension of Beck’s work. Beck’s cata- prognostic features, treated with aversion therapy log of distorted thoughts examined in depression and follow-up at an average of fifteen months after were found to be applicable to cognitive distortions treatment. Again there was no control group. and errors that accompany addictive disorders. Aversion treatment for cigarette smoking has Various cognitive treatments for substance abuse been studied by using appropriate controls. The focus on these distortions and vary primarily in the technique involves encouraging the smoker to keep techniques used to change these thought processes. inhaling at rapid intervals over a period of five to In RELAPSE PREVENTION (Marlatt & Gordon, ten minutes until he or she becomes sick, presum- 1985), cognitive distortions are viewed as instru- ably because the nicotine levels exceed the smoker’s mental in the process that leads to relapse. By tolerance levels. This approach has consistently helping the client thoroughly examine the thoughts produced higher levels of abstinence from smoking that accompany substance use, therapy can reduce than have control groups. the likelihood of a lapse (single use), as well as help prevent a lapse from becoming a relapse (return to (SEE ALSO: Calcium Carbimide; Disulfiram) uncontrolled use). This is accomplished by examining the following cognitive errors: BIBLIOGRAPHY 1. Overgeneralizing—this is one of the most fre- FRAWLEY, P. J., & SMITH, J. W. (1992). One-year fol- quently occurring cognitive errors that helps a low-up after multimodal inpatient treatment for co- single lapse become a full-blown relapse. By caine and methamphetamine dependencies. Journal viewing the single use as a sign of total relapse, of Substance Abuse Treatment, 9, 271–286. the client overgeneralizes the single use of a LEMERE, F., & VOEGTLIN, W. L. (1940). Conditioned substance as a symptom of total failure, thereby reflex therapy of alcoholic addiction: Specificity of allowing for increasing use over time and in a conditioning against chronic alcoholism. California variety of situations. This is sometimes referred and Western Medicine, 53(6), 1–4. to as the ABSTINENCE VIOLATION EFFECT (AVE). SMITH, J. W., & FRAWLEY, P. J. (1990). Long-term absti- 2. Selective abstraction—by excessively focusing nence from alcohol in patients receiving aversion ther- on the immediate lapse, with an accompanying apy as part of a multimodal inpatient program. Jour- neglect of all past accomplishments and learn- nal of Substance Abuse Treatment, 7, 77–82. ing, the client interprets a single slip as equiva- SMITH, J. W., FRAWLEY, P. J., & POLISSER (1991). Six- lent to total failure. The individual measures and twelve-month abstinence rates in inpatient alco- progress almost exclusively in terms of errors holics treated with aversion therapy compared with and weaknesses. 1230 TREATMENT TYPES: Cognitive Therapy

3. Excessive responsibility—by attributing the is encouraged to view the event as a chance to hone cause of a lapse to personal, internal weaknesses the skills required for abstinence, thereby coun- or lack of willpower, the client assumes total tering the cognitive errors of selective abstraction. responsibility for the slip, which in turn makes To intervene with the errors of overgeneraliza- reassuming control more difficult than when en- tion and temporal causality, the client is taught to vironmental factors are considered partially review a lapse as a specific, unique event in time and sponsible for the slip. space, instead of as a symptom with greater signifi- 4. Assuming temporal causality—here, the client cance attached to it (e.g., the beginning of the inev- views a slip as the first of many to come, thereby itable end). The errors of self-reference and dooming all future attempts at self-control. willpower breakdown can be countered by teaching 5. Self-reference—when the client thinks that a the client to reattribute a lapse to external, specific, lapse becomes the focus of everyone else’s atten- and controllable factors. By examining the diffi- tion, believing that others will attribute blame culty of the high-risk situation, the appropriateness for the event to the client, this adds to feelings of of the coping response employed, and any motiva- guilt and shame that may already be present tional deficits (fatigue or excessive stress), the client within the person. can maintain a sense of control over the event and 6. Catastrophizing—the client believes the worst the process of recovery. possible outcome will occur from a single use of Each of these techniques is aimed at conveying the substance instead of thinking about how to the idea that abstinence is the result of a learning cope successfully with the initial lapse. process, requiring an acquisition of skills similar to 7. Dichotomous thinking—by viewing events in many other skills one learns. This general meta- ‘‘black and white,’’ clients view their addictive phor can help the client reverse catastrophizing, by behavior exclusively in terms of abstinence or reframing a relapse as a ‘‘prolapse,’’ as a fall for- relapse and leave no logical room for ‘‘gray’’ ward rather than backward. This view, combined areas, where they can get back on track once a with viewing a lapse as a unique event in time, slip has occurred. helps the client maintain a sense of personal con- 8. Absolute willpower breakdown—here, the cli- trol, since abstinence or control is framed as just a ent assumes that once willpower has failed, loss moment away if use is discontinued. of control is inevitable, never to be regained. Several skills are taught to the client in relapse 9. Body over mind—the cognitive error here is prevention to facilitate these cognitive changes and assuming that once a single lapse has occurred, prevent future lapses. Identifying specific sources of the physiological process of addiction has exclu- stress that contribute to urges, cravings, or lapses sive control over subsequent behavior, making helps isolate the event in time as well as identify continued use inevitable. other distortions that may be present. For example, clients may identify discussing money with one’s These errors in thinking are targeted for change spouse as the high-risk situation that preceded a in relapse prevention by helping the client learn lapse. While discussing the lapse with a therapist, how to reattribute the cause of a lapse from inter- clients can learn to anticipate that discussing nal, stable, personal causes to mistakes or errors in money in the marriage may trigger an urge or the learning process. To facilitate the client’s sense craving to drink. Teaching clients to use visual of personal control, lapses are viewed as opportuni- imagery, such as viewing the urge as a wave that ties for corrective learning, instead of indications of they can surf, can help manage the feeling that total failure. Congruent with the research in the urges will continue to build until they must inevita- area (Shiffman, 1991), the therapist presents a bly be given in to. Self-talk is encouraged if a client lapse as a frequently occurring event in the journey believes this will help gain a sense of personal con- toward recovery. The therapist therefore encour- trol (such as reciting a phrase to oneself about the ages the client to examine the thoughts and expec- goal of abstinence or remembering who can be tancies that surround the lapse closely, with the telephoned when an urge is experienced). In addi- aim of learning alternative coping skills for similar tion, clients are taught to be alert for ‘‘apparently situations that may arise in the future. By re- irrelevant decisions,’’ which can inadvertently lead framing a lapse as a learning opportunity, the client to relapse. For example, an abstinent gambler may TREATMENT TYPES: Contingency Management 1231 decide to take a scenic drive through Reno, only to been used effectively in the treatment of a wide find a situation that would be extremely difficult for variety of forms of drug dependence, including many to ignore, thus in this case causing a relapse. amphetamine (Boudin, 1972), alcohol (Miller, Other theorists have developed treatments based 1975; Petry et al., 2000), cocaine (Higgins et al., exclusively on changing irrational thinking. Ellis 1993, 2000), marijuana (Budney at al., in press), and colleagues (1988) founded a self-help group nicotine (Donatelle et al., 2000), and opiates (Hall, network called RATIONAL RECOVERY (RR), based et al., 1979; Bickel et al., 1997). on the principles of rational emotive therapy. De- Contingency management involves an agree- veloped as an alternative to the ALCOHOLICS ment or contract that carefully stipulates the de- ANONYMOUS network, RR focuses on ‘‘addictive sired behavior change, the schedule and methods thinking’’ and views abstinence as possible— for monitoring progress, the consequences that will purely as a result of changing these thought pro- follow success or failure in making the behavior cesses. This differs from the relapse prevention change, and the duration of the contract. Practical model described above, which in its entirety com- details on the development and implementation of bines cognitive and behavioral techniques. Ellis’s CM interventions can be found in several sources RR movement teaches addicts how to identify, their (Budney & Higgins, 1998; Higgins & Silverman, own faulty thinking through a self-help manual 1999; Petry, 2000) (Trimpey, 1989) and the attendance at support The most common use of CM with drug-depen- groups. dent individuals is to reinforce abstinence from drug use. Numerous studies have demonstrated that providing incentives contingent on objective (SEE ALSO: Alcoholism; Causes of Substance Abuse; Disease Concept of Alcoholism and Drug Abuse) evidence of abstinence from recent drug use (e.g., negative urinalysis results) increases future abstinence (see Higgins & Silverman, 1999; Stitzer & BIBLIOGRAPHY Higgins, 1995). Although compelling evidence re- BECK, Aaron T. (1993). Cognitive therapy of substance garding the efficacy of CM has been available since abuse. New York: Guilford Press. the 1970s, interest in this treatment approach was CARROLL, Kathleen M. (1998). A cognitive behavioral bolstered substantially by successes achieved with approach: Treating cocaine addiction. Therapy Man- CM in the treatment of cocaine dependence. In a uals for Drug Addiction. U.S. Department of Health seminal study on that topic, thirty-eight cocaine- and Human Services: National Institute on Drug dependent adults were randomly assigned to Abuse. twenty-four weeks of behavior therapy including LIESE, Bruce S. & BECK, Aaron T. (1997). Back to basics: CM or to drug abuse counseling (Higgins et al., Fundamental cognitive therapy skills for keeping 1993). In the CM condition, vouchers redeemable drug-dependent individuals in treatment. In Lisa S. for retail items were earned by submitting speci- Onken, Jack D. Blaine, & John J. Boren (Eds), Beyond mens that tested negative for cocaine use in urine the therapeutic alliance: Keeping the drug-dependent toxicology testing. More than 50 percent of patients individual in treatment. NIDA Research Monograph in the CM condition remained in treatment for the 165, 207–232. U.S. Department of Health and Hu- recommended twenty-four weeks and achieved man Services: National Institute on Drug Abuse. several months of continuous cocaine abstinence while only 11 percent of patients in the comparison MOLLY CARNEY condition did so. Subsequent studies of CM in the REVISEDBY REBECCA HORN treatment of cocaine dependence replicated those findings and also demonstrated benefits during the year after treatment ended (Higgins et al., 2000; Contingency Management Contingency Silverman et al., 1996). These positive results with management (CM) is an intervention that promotes CM were particularly encouraging because so few behavior change by providing positive reinforce- other treatment approaches have been shown to be ment when treatment goals are achieved and with- efficacious with cocaine dependence. holding reinforcement or providing punitive conse- Most typically, but not always, CM is used as quences when undesirable behavior occurs. CM has part of a more comprehensive treatment plan. In- 1232 TREATMENT TYPES: Contingency Management deed, CM can be used to improve compliance with As illustrated in the preceding material, CM is other treatment regimens. Early studies with alco- effective in increasing drug abstinence and in im- holics, for example, demonstrated that CM could be proving compliance with treatment regimens for used to improve medication compliance among in- various types of drug dependence and populations. dividuals receiving disulfiram (Antabuse) therapy Positive outcomes have been achieved even with (Liebson et al., 1978). More recent studies have some of the most challenging and recalcitrant demonstrated CM’s efficacy in improving medica- subgroups of drug abusers. A notable shortcoming tion compliance among tuberculosis-exposed and associated with CM is a loss of treatment gains HIV-infected drug abusers (Elk, 1999; Rosen et al., when the intervention is terminated. As noted 2000). CM can also improve compliance with par- above, beneficial carryover effects have been dem- ticipation in therapy-related activities among opi- onstrated through a year or more posttreatment, ate-dependent patients (Bickel et al., 1997; Iguchi and the rates of relapse appear to be comparable to et al., 1997). In these applications, patients earned those observed among individuals treated with vouchers by completing some minimum number of other interventions. Nevertheless, relapse is an im- therapy-related activities weekly. The activities portant problem needing improvement. Systematic might include attending a job interview if the goal use of multimodel interventions designed to ad- was gaining employment, or attending a self-help dress the many changes likely to be necessary for meeting if the goal was to increase contact with a longer-term success is one reasonable approach, as social network to support sobriety. Vouchers were is the development of longer-term CM interventions provided when patients submitted documentation that can be kept in place until the patient gains the verifying that they had completed a designated requisite skills to sustain abstinence without CM therapeutic activity. Completion of therapeutic ac- support. tivities was associated with greater drug abstinence. BIBLIOGRAPHY CM is also proving to be capable of improving outcomes with important special populations of BICKEL, W. K., ET AL. (1997). Effects of adding behav- drug abusers. Improving adherence to medication ioral treatment to opioid detoxification with regimens among those with infectious diseases was buprenorphine. Journal of Consulting and Clinical noted above. Another special population is the seri- Psychology, 65, 803-810. ously mentally ill who are also drug-dependent. Re- BOUDIN, H. M. (1972). Contingency contracting as a sults from several preliminary studies indicate that therapeutic tool in the reduction of amphetamine use. CM may be effective in reducing cigarette smoking Behavior Therapy, 14, 378-381. (Roll et al., 1998), cocaine use (Shaner et al., BUDNEY,A.J.,&HIGGINS, S. T. (1998). The community 1997), and marijuana use (Sigmon et al., in press) reinforcement plus vouchers approach: Manual 2: among individuals with schizophrenia. CM is an National Institute on Drug Abuse therapy manuals for integral component of a multielement treatment drug addiction. NIH publication ࠻ 98-4308. Rock- that is efficacious in the treatment of homeless ville, MD: National Institute on Drug Abuse. crack and other drug abusers (Milby et al., 2000). BUDNEY, A. J., ET AL. (in press). Adding voucher-based Another special group for whom effective treat- incentives to coping skills and motivational enhance- ments are sorely needed is drug-dependent preg- ment improves outcomes during treatment for mari- nant women. A voucher-based CM intervention has juana dependence. Journal of Consulting and Clinical been demonstrated to significantly increase absti- Psychology. nence from cocaine and heroin use while simulta- DONATELLE, R. J., ET AL. (2000). Randomized controlled neously increasing vocational skills among preg- trial using social support and financial incentives for nant women who were both drug dependent and high-risk pregnant smokers: The Significant-Other chronically unemployed (Silverman et al., in Supporter (SOS) Program. Tobacco Control,9, press). In another effective CM intervention with iii67-iii69. pregnant women, vouchers delivered contingent on ELK, R. (1999). Pregnant women and tuberculosis-ex- abstinence from cigarette smoking increased cessa- posed drug abusers: Reducing drug use and increas- tion rates during pregnancy and postpartum (Do- ing treatment compliance. In S.T. Higgins & K. Sil- natelle et al., 2000). verman (Eds.), Motivating behavior change among TREATMENT TYPES: Group and Family Therapy 1233

illicit-drug abusers: Research on contingency man- SHANER, A., ET AL. (1997). Monetary reinforcement of agement interventions 123-144. Washington, DC: abstinence from cocaine among mentally ill patients American Psychological Association. with cocaine dependence. Psychiatric Services, 48, HALL, S. M., ETAL. (1979). Contingency management 807-810. and information feedback in outpatient heroin detoxi- SIGMON, S. C., ET AL. (in press). Contingent reinforce- fication. Behavior Therapy, 10, 443-451. ment of marijuana abstinence among individuals with HIGGINS, S. T., ET AL. (1993). Achieving cocaine absti- serious mental illness: A feasibility study. Experimen- nence with a behavioral approach. American Journal tal and Clinical Psychopharmacology. of Psychiatry, 150, 763-769. SILVERMAN, K., ET AL. (1996). Sustained cocaine absti- HIGGINS, S. T., & SILVERMAN, K. (1999). Motivating be- nence in methadone maintenance patients through havior change among illicit-drug abusers: Research voucher-based reinforcement therapy. Archives of on contingency management interventions. Washing- General Psychiatry, 53, 409-415. ton, DC: American Psychological Association. SILVERMAN, K., ET AL. (in press). A reinforcement-based HIGGINS, S. T., ET AL. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treat- therapeutic workplace for the treatment of drug ment and one year of follow-up. Journal of Consulting abuse: 6-month abstinence outcomes. Experimental and Clinical Psychology, 68, 64-72. and Clinical Psychopharmacology. IGUCHi, M. Y., ET AL. (1997). Reinforcing operants other STITZER,M.L.&HIGGINS, S. T. (1995). Behavioral than abstinence in drug abuse treatment: An effective treatment of drug and alcohol abuse. In F.E. Bloom & alternative for reducing drug use. Journal of Consult- D.J. Kupfer (Eds.), Psychopharmacology: The fourth ing and Clinical Psychology, 65, 421-428. generation of progress 1807-1819. New York: Raven LIEBSON, I. A., TOMMASELLO, A., & BIGELOW,G.E. Press. (1978). A behavioral treatment of alcoholic metha- STEPHEN T. HIGGINS done patients. Annals of Internal Medicine, 89, 342- ALAN J. BUDREY 344. SARAH HEIL MILBY, J. B., ET AL. (2000). Initiating abstinence in cocaine-abusing dually diagnosed homeless persons. Drug and Alcohol Dependence, 60, 55-67. MILLER, P. M. (1975). A behavioral intervention pro- Group and Family Therapy The illnesses gram for chronic drunkenness offenders. Archives of of drug addiction and alcoholism are so severe that General Psychiatry, 32, 915-918. they pervade every aspect of an individual’s exis- PETRY, N. M. (2000). A comprehensive guide to the ap- tence. It is rare that so extensive an illness can be plication of contingency management procedures in reversed by individual therapy alone. Thus thera- clinical settings. Drug and Alcohol Dependence, 58, pists are espousing an integration of individual, 9-25. TWELVE-STEP, group, and family treatment, with PETRY, N. M., ET AL. (2000). Give them prizes and they specific combinations of treatments tailored to each will come: Contingency management treatment of al- individual’s needs. cohol dependence. Journal of Consulting and Clinical Dealing with the family is one more involvement Psychology, 68, 250-257. with the patient’s ecosystem, which includes work- ROLL, J. M., ET AL. (1998). Use of monetary reinforce- ing with the treatment team, twelve-step groups, ment to reduce the cigarette smoking of persons with sponsors, employers, EAPs (EMPLOYEE ASSISTANCE schizophrenia: A feasibility study. Experimental and PROGRAM counselors), managed-care workers, pa- Clinical Psychopharmacology, 6, 157-161. role officers, and other members of the legal sys- ROSEN, M. I., ET AL. (2000). Monetary reinforcement combined with structured training increases compli- tem. However, family work is most critical to the ance to antiretroviral therapy. In L.S. Harris (Ed.), success of treatment. Problems of drug dependence, 1999: proceedings of Group therapy has frequently been designated the 61st annual scientific meeting, The College on as the treatment of choice for addicted patients. Problems of Drug Dependence, Inc. NIDA Research This article views group therapy as an essential Monograph 180. NIH publication ࠻ 00-4737. Be- component of the integrated, individualized ap- thesda, MD: National Institute on Drug Abuse. proach to addicts and alcoholics. 1234 TREATMENT TYPES: Group and Family Therapy

FAMILY THERAPY If substance abuse is moderately severe or intermittent and without physical dependence, such as The family treatment of substance abuse begins intermittent use of HALLUCINOGENS or weekend with developing a system to achieve and maintain COCAINE abuse, the family is offered a variety of abstinence. This system, together with specific fam- measures, such as regular attendance at ALCOHOL- ily therapeutic techniques and knowledge of pat- ICS ANONYMOUS (AA), NARCOTICS ANONYMOUS terns commonly seen in families with a substance- (NA), or COCAINE ANONYMOUS (CA) for the IP and abusing member, provides a workable, therapeutic Al-Anon or Naranon for family members. approach to substance abuse. If these methods fail, short-term hospitalization Family treatment of substance abuse must begin or treatment in an intensive outpatient program with an assessment of the extent of substance dependence as well as the difficulties it presents for (20 hours or more per week) may be necessary to the individual and the family. The quantification of establish a substance-free state and to begin effec- substance-abuse history can take place with the tive treatment even with nondependent patients. In entire family present; substance abusers often will more severe cases of drug abuse and dependence, be honest in this setting, and ‘‘confession’’ is a help- more aggressive methods are necessary to establish ful way to begin communication. Moreover, other a substance-free state. family members can often provide more accurate Family Education. A substantial amount of information than the substance abusers (also family education is generally very helpful in the known as the identified patient, IP). However, early stages of the family’s involvement in therapy. some IPs will give an accurate history only when In many inpatient addiction treatment programs, interviewed alone. the family spends several days or more receiving In taking a drug-abuse history, it is important to appropriate education. If this is not available, the know current and past use of every type of abusable therapist should include this education process in drug as well as of ALCOHOL: quantity, quality, du- early sessions. ration, expense, how intake was supported and Some of the issues covered by this educational prevented, physical effects, tolerance, withdrawal, emphasis are: (1) the physiological and psychologi- and medical complications. At times, other past cal effects of drugs and alcohol; (2) the disease con- and present substance abusers within the family cept; (3) cross addiction (which helps families are identified; their own use and its consequences learn that a recovering cocaine addict should not should be quantified without putting the family on drink or vice versa); (4) common family systems— the defensive. It is also essential to document the emphasizing the family’s roles in addiction and family’s patterns of reactivity to drug use and recovery, including enabling, scapegoating, and abuse. Previous attempts at abstinence and treat- CODEPENDENCY; (5) the phases of treatment, with ment are reviewed to determine components of suc- an emphasis on the deceptiveness of the ‘‘honey- cess and failure. The specific method necessary to moon’’ period in early recovery; and (6) the impor- achieve abstinence can be decided only after the tance of twelve-step family support groups (AL-AN- extent and nature of substance abuse are quanti- ON,ALATEEN). fied. Working with Families with Continued Drug Establishing a System to Achieve a Sub- Abuse. The family therapist is in a unique posi- stance-Free State. It is critical first to establish a tion with regard to continued substance abuse and system for enabling the substance abuser to become other manifestations of the IP’s resistance to treat- drug-free, so that family therapy can be effective. ment, including total nonparticipation. The family The specific methods employed to achieve absti- therapist still has a workable and highly motivated nence vary according to the extent of use, abuse, patient(s): the family. One technique that can be and dependence. Mild-to-moderate abuse in ado- used with an absent or highly resistant patient is lescents can often be controlled if both parents the intervention, which was developed for use with agree on clear limits and expectations, and how to alcoholics but can be readily adapted to work with enforce them. Older abusers may stop if they are drug abusers, particularly those who are middle aware of the medical or psychological consequences class, involved with their nuclear families, and em- to themselves or the effects on their family. ployed. TREATMENT TYPES: Group and Family Therapy 1235

In this technique, the family (excluding the the drug abuser; or (3) separate or physically dis- abuser) and significant network members (e.g., tance yourself. When the client does not change, it employer, fellow employees, friends, and neigh- is labeled an overt choice 1. When a client does not bors) are coached to confront the subtance abuser choose 2 or 3, the therapist can point out that he or with concern, but without hostility, about the de- she is in effect choosing not to change. If not chang- structiveness of his or her drug abuse and behavior. ing becomes a choice, then the SO can be helped to They agree in advance about what treatment is choose to make a change. In choice 2, SOs are necessary and then insist on it. As many family helped to avoid overreacting emotionally to drug members as possible should be included, because abuse and related behavior, and they are taught the breakthrough for acceptance of treatment may strategies for emotional detachment. Leaving, come from an apparently uninvolved family mem- choice 3, is often difficult when the family is emo- ber, such as a grandchild or cousin. The involve- tionally or financially dependent on the substance ment of the employer is crucial, and in some cases abuser. may be sufficient in and of itself to motivate the Each of these choices seems impossible to carry drug abuser to seek treatment. The employer who out at first. The problem of choosing may be re- clearly makes treatment a condition of continued solved by experiencing the helplessness and power- employment, who supports time off for treatment, lessness in pursuing each choice. and who guarantees a job on completion of the As part of the initial contract with a family, it is initial treatment course is a very valuable ally. The suggested that the abuser’s partner continue indi- employer’s model is also a very helpful one for the vidual treatment, Al-Anon, Coanon, or an SO family, who need to be able to say ‘‘We love you, group even if the abuser drops out. Other family and because we love you, we will not continue to members are also encouraged to continue in family live with you if you continue to abuse drugs and therapy and support groups. It should be reempha- alcohol. If you accept the treatment being offered to sized that whenever therapy is maintained with a you and continue to stay off drugs, we will renew family in which serious drug abuse continues, the our lifetime commitment to you.’’ therapist has the responsibility of not maintaining If substance abusers do not meet the above crite- the illusion that the family is resolving problems, ria for an intervention or if the intervention has when in fact they are really reinforcing them. Even failed, we are left with the problems of dealing with when the substance abuser does not participate in a substance-abusing family. Berenson (1976) of- treatment, however, therapy may be quite helpful fers a workable, three-step therapeutic strategy for to the rest of the family. dealing with the spouses or other family members The concept of the family as a multigenerational of individuals who continue to abuse substances or system necessitates that the entire family be in- who are substance dependent. Step one is to calm volved in treatment. The family members for opti- down the family by explaining problems, solutions, mum treatment consist of the entire household and and coping mechanisms. Step two is to create an any relatives who maintain regular (approximately external support network for family members so weekly) contact with the family. In addition, rela- that the emotional intensity is not all in the relatively emancipated family members who have less tionship with the substance abuser or redirected to than weekly contact may be very helpful to these the therapist. There are two types of support sys- families. tems available to these spouses. One is a self-help The utilization of a multigenerational approach group on the Al-Anon, Naranon, or Coanon model; involving grandparents, parents, spouse, and chil- the other is a significant others (SO) group led by a dren at the beginning, as well as certain key points trained therapist. In the former, the group and throughout, family therapy is advised. However, sponsor provide emotional support, reinforce de- the key unit with substance abusers younger than tachment, and help calm the family. An SO group about age 24 is the IP with siblings and parents. may provide more insight and less support for re- The critical unit with married substance abusers maining with a substance-abusing spouse. older than 24 is the IP and spouse. However, the Step three involves giving the client three more dependent the IP is on the parents, the more choices: (1) keep doing exactly what you are doing; critical is family work with these parents. The ma- (2) detach or emotionally distance yourself from jority of sessions should be held with these family 1236 TREATMENT TYPES: Group and Family Therapy units; the participation of other family members is According to strategic therapists, symptoms are essential to more thorough understanding and per- maladaptive attempts to deal with difficulties, manent change in the family. which develop a homeostatic life of their own and Family therapy limited to any dyad is most diffi- continue to regulate family transactions. The stra- cult. The mother-addicted-son dyad is almost im- tegic therapist works to substitute new behavior possible to treat as a sole entity; some other signifi- patterns for the destructive repetitive cycles. The cant person, such as a lover, grandparent, aunt, or techniques used by strategic therapists include the uncle should be brought in if treatment is to suc- following: ceed. If there is absolutely no one else available 1. Using tasks with the therapist responsible for from the natural family network, then surrogate planning a strategy to solve the family’s prob- family members in multiple-family therapy groups lems. can provide support and leverage to facilitate re- 2. Putting the problem in solvable form. structuring maneuvers. 3. Placing considerable emphasis on change outside the sessions. AN INTEGRATED APPROACH TO A 4. Learning to take the path of least resistance, so WORKABLE SYSTEM OF that the family’s existing behaviors are used FAMILY TREATMENT positively. Family Diagnosis. Accurate diagnosis is as 5. Using paradox, including restraining change important a cornerstone of family therapy as it is in and exaggerating family roles. individual therapy. Family diagnosis looks at fam- 6. Allowing the change to occur in stages; the family interaction and communication patterns and re- ily hierarchy may be shifted to a different, ab- lationships. In assessing a family, it is helpful to normal one before it is reorganized into a new construct a map of the basic alliances and roles, as functional hierarchy. well as to examine the family rules, boundaries, 7. Using metaphorical directives in which the fam- and adaptability. ily members do not know they have received a Family Treatment Techniques. Each system directive. of family therapy presently in use is briefly summa- Stanton et al. (1982) successfully utilized an rized below, with an emphasis on the application of integrated structural-strategic approach with her- these techniques to substance abusers. They are oin addicts on METHADONE MAINTENANCE treat- classified into four schools: structural-strategic, ment. psychodynamic, Bowen’s systems theory, and be- Psychodynamic Therapy. This approach has rarely havioral. Any of these types can be applied to sub- been applied to substance abusers because they stance abusers if their common family patterns are usually require a more active, limit-setting empha- kept in mind and if a method to control substance sis on the here and now than is generally associated abuse is implemented. with psychodynamic techniques. However, if cer- Structural-Strategic Therapy. These two types are tain basic limitations are kept in mind, psychody- combined because they were developed by many of namic principles can be extremely helpful in the the same practitioners, and shifts between the two family therapy of these patients. are frequently made by the therapist, depending on There are two cornerstones for the implementa- the family’s needs. The thrust of structural family tion of psychodynamic techniques: the therapist’s therapy is to restructure the system by creating self-knowledge and a detailed history of the sub- interactional change within the session. The thera- stance abuser’s family. pist actively becomes a part of the family, yet re- Important elements of psychodynamic family tains sufficient autonomy to restructure it. The therapy include the following: techniques of structural therapy have been described in detail by Kaufman (1985). They include countertransference—The therapist may have the contract, joining, actualization, marking a countertransference problem toward boundaries, assigning tasks, reframing, the para- the entire family or any individual mem- dox, balancing and unbalancing, and creating in- ber of the family, and may get into power tensity. struggles or overreact emotionally to af- TREATMENT TYPES: Group and Family Therapy 1237

fect, content, or personality. The IP’s de- the use of affect is minimized. Systems theory fo- pendency, relationship suction and repul- cuses on triangulation, which implies that when- sion, manipulativeness, denial, ever there is emotional distance or conflict between impulsivity, and family role abandon- two individuals, tensions will be displaced onto a ment may readily provoke counter- third party, issue, or substance. Drugs are fre- transference reactions in the therapist. quently the subject of triangulation. However, family therapists view their Behavioral Family Therapy. This approach is com- emotional reactions to families in a sys- monly used with substance-abusing ADOLESCENTS. tems framework as well as a counter- Its popularity may be attributed to the fact that it transference context. Thus they must be can be elaborated in clear, easily learned steps. aware of how families will replay their Noel and McCrady (1984) developed seven steps problems in therapy by attempting to de- in the therapy of alcoholic couples that can readily tour or triangulate their problems onto be applied to married adult drug abusers and their the therapist. The therapist must be par- families: ticularly sensitive to the possibility of be- 1. Functional analysis. Families are taught to un- coming an enabler who, like the family, derstand the interactions that maintain drug protects or rejects the substance abuser. abuse. the role of interpretation—Interpretations can 2. Stimulus control. Drug use is viewed ‘‘as a habit be extremely helpful if they are made in a triggered by certain antecedents and main- complementary way, without blaming, tained by certain consequences.’’ The family is guilt induction, or dwelling on the hope- taught to avoid or change these triggers. lessness of longstanding, fixed patterns. 3. Rearranging contingencies. The family is taught Repetitive patterns and their maladpative techniques to provide reinforcement for efforts aspects for each family member can be at achieving a drug-free state by frequent re- pointed out, and tasks can be given to viewing of positive and negative consequences help change these patterns. Some families of drug use and self-contracting for goals and need interpretations before they can fulfill specific rewards for achieving these goals. tasks. An emphasis on mutual responsi- 4. Cognitive restructuring. IPs are taught to mod- bility when making any interpretation is ify self-derogatory, retaliatory, or guilt-related an example of a beneficial fusion of struc- thoughts. They question the logic of these ‘‘irra- tural and psychodynamic therapy. tional’’ thoughts and replace them with more overcoming resistance—Resistance is defined ‘‘rational’’ ideation. as behaviors, feelings, patterns, or styles 5. Planning alternatives to drug use. IPs are taught that prevent change. In substance-abus- techniques for refusing drugs through role-playing families, key resistance behaviors that ing and covert reinforcement. must be dealt with involve the failure to 6. Problem solving and assertion. The IP and fam- perform functions that enable the abuser ily are helped to decide if a situation calls for an to stay ‘‘clean.’’ assertive response and then, through role-play- Every substance-abusing family has character- ing, to develop effective assertive techniques. istic patterns of resistant behavior, in addition to IPs are to perform these techniques twice daily individual resistances. This family style may con- and to utilize them in situations that would have previously triggered the urge to use drugs. tribute significantly by resistance; some families 7. Maintenance planning. The entire course of may need to deny all conflict and emotion, and are therapy is reviewed, and the new armamentar- almost totally unable to tolerate any displays of ium of skills is emphasized. IPs are encouraged anger or sadness; others may overreact to the to practice these skills regularly as well as to slightest disagreement. It is important to recognize, reread handout materials that explain and rein- emphasize, and interpret the circumstances that force these skills. arouse resistance patterns. Bowen’s Systems Family Therapy. In Bowen’s Families can also be taught through behavioral (1974) approach, the cognitive is emphasized and techniques to become aware of their nonverbal 1238 TREATMENT TYPES: Group and Family Therapy communication, so as to make the nonverbal mes- In hospital settings, educational groups are an sage concordant with the verbal and to learn to essential part of the early treatment process, and express interpersonal warmth nonverbally as well the subjects covered in these groups are quite simi- as verbally. lar to those in educational family groups (described in the first section of this article). The major difference of emphasis in patient educational groups is FAMILY READJUSTMENT on the physiological aspects and risk factors of AFTER CESSATION drugs and alcohol. Other important didactic groups Once the substance abuse has stopped, the fam- cover in detail issues such as (1) ASSERTIVENESS ily may enter a honeymoon phase in which major TRAINING; (2) other compulsive behaviors, such as conflicts are denied. They may maintain a superfi- sexuality, eating, working, and GAMBLING; (3) RE- cial harmony based on relief and suppression of LAPSE PREVENTION; (4) the prolonged abstinence negative feelings. When the drug-dependent person syndrome; (5) leisure skills; and (6) cross addic- stops using drugs, however, other family problems tion. All educational groups include appropriate may be uncovered, particularly in the parents’ coping strategies, some of which are developed marriage or in other siblings. These problems, from the experiences of recovering members. which were present all along but obscured by the One advantage of 28-day residential programs IP’s drug use, will be ‘‘resolved’’ by the IP’s return (now more often 7 to 21 days, followed by an to symptomatic behavior if they are not dealt with intensive 6-hours-a-day outpatient program) is in family therapy. In the latter case, the family that group therapy can be started immediately af- reunites around their problem person, according to ter drinking or drug use stops. In the first few sober days, the addict or alcoholic is so needy that his/her their old, familiar pathological style. resistance to groups is low. At this stage, the thera- Too many treatment programs in the substance- pist and the group should show the substance abuse field focus their efforts on brief, high-impact abuser how to borrow the confidence that life with- treatment, neglecting aftercare. Many of these pro- out alcohol or drugs is possible and better than life grams include a brief, intensive family educational with it. This hope is best offered by a therapist or and therapeutic experience, but have even less fo- cotherapist who is a recovering substance abuser cus on the family in aftercare than on the IP. These with solid sobriety. Therapeutic groups in these intensive, short-term programs have great impact settings will also deal with appropriate expressions on the family system, but only temporarily. The of feelings, relationships with significant others, pull of the family homeostatic system will draw the childhood molestation and abuse, building self-es- IP and/or other family members back to symptom- teem, and development of strategies for self-care. atic behavior. The family must be worked with for A critical aspect of early group therapy is for the months, and often years, after substance abuse first patient to experience the sharing of a group of abates if a drug-free state is to continue. In addi- individuals struggling against their addiction. This tion, ongoing family therapy is necessary for the helps to overcome the feelings of isolation and emotional well-being of the IP and other family shame that are so common in these patients. The members. formation of a helping, sober peer group that provides support for a lifetime, in and out of twelve- GROUP THERAPY step groups, is very helpful and dramatic when it occurs. Group therapy varies with each of the three In outpatient programs there is less of an oppor- phases in the psychotherapy of substance abusers: tunity to perform uncovering therapy in the early achieving abstinence, early SOBRIETY, and late so- phases because there is less protection and less of a briety (achieving intimacy). holding environment than in residential settings. Early Phase: Achieving Abstinence. In the Others, particularly Woody et al. (1986), have first phase of psychotherapy, the type of group developed detailed group therapy techniques for utilized will depend on the treatment setting: hospi- methadone patients. Also, Brown and Yalom tal, residential, intensive outpatient (also termed (1977) and Vanicelli (1992), with alcoholics, and partial hospitalization), or limited outpatient. Khantzian et al. (1990), with cocaine addicts, have TREATMENT TYPES: Group and Family Therapy 1239 adapted psychodynamic techniques for group Gradually, tentative overtures of friendship and work. understanding become manifest. There may be a Ex-addicts and recovering alcoholics are valu- conspiracy of silence about material that members able as cotherapists, or even as primary or sole fear could cause discomfort or lead to drug use or therapist, particularly in the early stages of groups. drinking. The therapists can point out to the mem- Commonality of experience with the client, by it- bers that they choose to remain static and within self, does not qualify an individual to be a therapist. comfortable defenses rather than expose them- Recovering persons should have at least two years selves to the discomfort associated with change. of sobriety before they are permitted to function as Patients usually drop out early if they are still group therapists. The techniques that help committed to using drugs or drinking. Other pa- ex-addicts become experienced therapists are best tients who drop out early do so because they grow learned gradually and under close supervision, increasingly alarmed as they become aware of the preferably by experienced paraprofessionals and degree of discomfort that any significant change professionals. requires. Also helpful in cotherapy is male-female pairing, Middle Phase: Early Sobriety. In the middle which provides a balance of male and female role phase of group therapy, the emphasis is quite simi- models and transference. lar to that of individual therapy. Therapists should During the early sessions of group therapy with continue to focus on cognitive behavioral tech- substance abusers, the focus is on the shared prob- niques to maintain sobriety. Intensive affects are lem of drinking or drug use, and its meaning to abreacted toward significant persons outside of the each individual. The therapist should be more ac- group but are minimized and modulated between group members. In this stage there evolves a begin- tive in this phase, which should be instructional ning awareness of the role of personality and social and informative as well as therapeutic. interactions in the use of drugs and alcohol. Alco- Alcoholics tend toward confessionals and mono- holics are ambivalent about positive feedback. logues about prior drinking. These can be politely They beg for it, yet reject it when it is given. They interrupted or minimized by a ground rule of ‘‘no repeatedly ask for physical reassurance, such as a drunkalogues.’’ Romanticizing past use of drugs or warm hug, but may panic when they receive it alcohol is strongly discouraged. because of fear of intimacy and a reexperiencing of Outpatient Groups. The desire to drink or use their unmet past needs. There is a fear of success drugs and the fear of slipping are pervasive, early and a dread of competing in life as well as in the concerns in outpatient groups. The patient’s atti- group. Success means destroying the other group tude is one of resistance and caution, combined members (siblings) and loss of therapist (parent). with fear of open exploration. Members are encour- Alcoholics are reluctant to explore fantasies be- aged to participate in AA and other relevant cause the thought makes them feel as guilty as the twelve-step groups, yet the ‘‘high support, low con- act. They view emotions as black or white. This flict, inspirational style’’ of AA may inhibit at- makes them withhold critical comments because tempts at interactional therapy. Therapists should they fear their criticism will provoke upset and the not be overly protective and prematurely relieve the resumption of drinking in other members. This group’s anxiety because this fosters denial of emo- withholding may be conscious or unconscious. tions. On the other hand, the members’ recognition Rage has been expressed either explosively or not at of emotions and responsibility must proceed slowly all. Its expression in the middle phase of group because both are particularly threatening to sub- should be encouraged, but gradually and under stance abusers. Patients are superficially friendly, slowly releasing controls. but do not show real warmth or tenderness. The other crucial affect that must be dealt with AA-type hugs are an easy way to begin to show is depression. There is an initial severe depression, physical support. They are afraid to express anger which occurs immediately after detoxification. It or to assert themselves. However, sudden irritation, appears to be severe but usually remits rapidly, antipathy, and anger toward the leaders and other leaving the substance abuser with a chronic, low- members inevitably begin to become more overt as grade depression—frequently expressed by silence, the group progresses. lack of energy, and vegetative signs. These patients 1240 TREATMENT TYPES: Group and Family Therapy should be drawn out slowly and patiently. Ulti- combined with empathy for others, and has scaled mately, they are encouraged to cry or mourn, and a down inordinate demands on others for superego distinction is made between helping them deal with reassurance. He or she has become effectively as- despair as opposed to rushing to take it away from sertive rather than destructively aggressive and has them. developed a reasonable sense of values. More ful- The success of the middle phase of group ther- filling relationships with spouse, children, and apy with substance abusers depends on the thera- friends can be achieved. pist’s and the group’s ability to relieve anxiety When members leave the group, the decision to through support, insight, and the use of more adap- leave should be discussed for several weeks before a tive, concrete ways of dealing with anxiety. Alcohol final date is set. This permits the group to mourn and drugs must become unacceptable solutions to the lost member and for the member to mourn the anxiety. In this vein, it is important not to end a group. This is true regardless of the stage of the session with members in a state of grossly unre- group, but the most intense work is done in the solved conflict. This can be avoided by closure later phases. In open-ended groups, the leadership when excessively troubling issues are raised. Clo- qualities of the graduating member are taken over sure can be achieved by the group’s concrete sug- by others, who then may apply these qualities to life gestions for problem solution. When this is not outside the group. possible, group support, including extragroup con- By the time substance abusers have reached this tact by members, can be offered. Brown and Yalom phase, they act like patients in highly functioning (1977) utilize a summary of the content of each neurotic groups. Other forms of group treatment group that is mailed to members between sessions combine the principles of group and family work, and helps provide closure and synthesis. such as multiple family group treatment and cou- Final Phase: Late Sobriety. In the final phase ples groups. of therapy, substance abusers express and work Multiple Family Group Treatment (MFGT). through feelings, responsibility for behavior, inter- This is a technique that can be used in any treat- personal interactions, and the functions and secon- ment setting for substance abusers but is most dary gain of drugs and alcohol. In this phase, re- successful in hospital and residential settings, constructive group techniques as practiced by well- where family members are usually more available. trained professionals are extremely helpful and es- In a residential setting, the group may be composed sential if significant shifts in ego strength are to be of all of the families or separated into several accomplished. Here, the substance abuser will be- groups of three or four closely matched families. come able to analyze defenses, resistance, and Most MGFTs now include the entire community transference. The multiple transferences that de- because this provides a sense of the entire patient velop in the group are recognized as ‘‘old tapes’’ group as a supportive family. In residential settings that are not relevant to the present. Problems of these groups are held weekly for two or three hours. sibling rivalry, competition with authority, and In hospitals, a family week or weekend is often separation anxiety become manifest in the group, offered as an alternative or adjunct to a weekly and their transference aspects are developed and group. interpreted. Conflicts are analyzed on both the in- Couples Groups. There are two types of cou- trapsychic and interpersonal levels. Ventilation ples groups: one for the parents of young substance and catharsis take place, and may be enhanced by abusers and one for the significant other and the group support. Excessive reliance on fantasy is substance abuser. abandoned. Couples often have difficulty dealing with the Alcoholics who survive a high initial dropout role of their own issues in family or other couple rate stay in groups longer than neurotic patients, therapy dysfunction when the children are present. and thus a substantial number of middle-phase This boundary is generally appropriate, and thus alcoholics will reach this final phase. By the closing ongoing couples groups should be an integral part phase, the alcoholic has accepted sobriety without of any family-based treatment program. resentment and works to free himself or herself When the presenting problem of substance from unnecessary neurotic and character problems. abuse is resolved, content shifts to marital prob- He or she has developed a healthy self-concept, lems. It is often at this point that parents want to TREATMENT TYPES: Group and Family Therapy 1241 leave the MFGT and attend a couples group. In a tracts; Families and Drug Use; Sobriety; couples group, procedures are reversed. Couples Toughlove) should not speak about their children but, rather, focus on the relationship between themselves. If BIBLIOGRAPHY material is brought up about the children, it is allowed only if it is relevant to problems that the ABLON, J. (1974). Al-Anon family groups. American couples have. Journal of Psychotherapy, 28, 30–45. Couples must support each other while learning ANDERSON, C. M., & STEWART, S. (1983). Mastering re- the basic tools of communication. When one part- sistance: A practical guide to family therapy. New ner gives up substance misuse, the nonusing part- York: Guilford Press. ner must adjust the way he or she relates to the BERENSON, D. (1976). Alcohol and the family system. In formerly using partner. There are totally new P. J. Guerin (Ed.), Family therapy. New York: Gard- expectations and demands. Sex may have been ner. used for exploitation and pacification so often that BOWEN, M. (1974). Alcoholism as viewed through family both partners have given up hope of resuming sex- systems therapy and family psychotherapy. Annals of ual relations and have stopped serious efforts the New York Academy of Sciences, 233, 114. toward mutual satisfaction. In addition, drugs and BROWN, S., & YALOM, I. D. (1977). Interactional group alcohol may have physiologically diminished the therapy with alcoholics. Journal of Studies on Alcohol, sex drive. Sexual communication must be slowly 38, 426–456. redeveloped. Difficulties may arise because the re- CADOGAN, D. A. (1973). Marital group therapy in the covering abuser has given up the most precious treatment of alcoholism. Quarterly Journal of Studies thing in his or her life (drugs or alcohol) and ex- on Alcohol, 34, 1187–1197. pects immediate rewards. The spouse has been CAHN, S. (1970). The treatment of alcoholics: An evalu- ‘‘burned’’ too many times (and is unwilling to pro- ative study. New York: Oxford University Press. vide rewards when sobriety stabilizes the spouse) to FOX, R. (1962). Group psychotherapy with alcoholics. trust one more time; at the same time the recov- International Journal of Group Psychotherapy, 12, ering abuser is asked to reevaluate expectations for 56–63. trust. HOFFMAN, H., NOEM, A. A., & PETERSEN, D. (1976). Couples groups in an adult or an adolescent pro- Treatment effectiveness as judged by successfully and gram provide a natural means for strengthening unsuccessfully treated alcoholics. Drug and Alcohol intimacy. Spouses are encouraged to attend Dependence, 1, 241–246. Al-Anon, Naranon, Coanon, and Coda to help di- JOHNSON, V. E. (1980). I’ll quit tomorrow (rev. ed.). San minish their reactivity and enhance their coping Francisco: Harper & Row. and self-esteem. KAUFMAN, E. (1994). Psychotherapy of addicted per- Couples groups have been used even more sons. New York: Guilford Publications. widely with alcoholics than with drug abusers, and KAUFMAN, E. (1985). Substance abuse and family ther- the techniques are similar to those described above. apy. New York: Grune & Stratton. Spouses of alcoholics are encouraged to attend KAUFMAN, E. (1982). Group therapy for substance abus- Al-Anon, which facilitates an attitude of loving ers. In M. Grotjahn, C. Friedman, & F. Kline (Eds.), A detachment. handbook of group therapy. New York: Van Nostrand Many studies have demonstrated that spousal Reinhold. involvement facilitates the alcoholic’s participation KAUFMAN, E., & KAUFMAN, P. (1992). Family therapy of in treatment and aftercare. It also increases the drug and alcohol abuse (2nd ed.). Boston: Allyn & incidence of sobriety and enhanced function after Bacon. treatment. Further, the greater the involvement of KAUFMAN, E., & KAUFMAN, P. (1979). Family therapy of the spouse in different group modalities (Al-Anon, drug and alcohol abuse. New York: Gardner. spouse groups, etc.), the better the prognosis for KHANTZIAN, E. J., HALLIDAY, D. S., & MCAULIFFE,W.E. treatment of the alcoholic. (1990). Addiction and the vulnerable self. New York: Guilford Press. (SEE ALSO: Causes of Substance Abuse; MCCRADY, B., ET AL. (1986). Comparative effectiveness Comorbidity and Vulnerability; Contingency Con- of three types of spousal involvement in outpatient 1242 TREATMENT TYPES: Hypnosis

behavioral alcoholism treatment. Journal of the Stud- substance and able to control the desire for it. A ies of Alcohol, 14(6), 459–467. third approach involves instructing subjects to re- MINUCHIN, S. (1974). Families and family therapy. Cam- duce or eliminate their craving for the drug. A bridge, MA: Harvard University Press. fourth involves cognitive restructuring, diminish- NOEL,N.E.&MCCRADY, B. (1984). Behavioral treating the importance of the craving for the drug by ment of an alcohol abuser with a spouse present. In E. focusing instead on a commitment to respect and Kaufman (Ed.), Power to change: Family case studies protect the body by eliminating the damaging drug. in the treatment of alcoholism. New York: Gardner. One widely used technique for smoking control, for STANTON,M.D.,ET AL. (1982). The family therapy of example, has people in hypnosis repeat to them- drug abuse and addiction. New York: Guilford Press. selves three points: (1) For my body, smoking is a VANICELLI, M. (1992). Removing the roadblocks. New poison; (2) I need my body to live; (3) I owe my York: Guilford Press. body respect and protection. This approach places WOODY, G. E., ET AL. (1986). Psychotherapy for sub- an emphasis on a positive commitment to what the stance abuse. Psychiatric Clinics North America, 9, person is for, rather than paying attention to being 547–562. against the drug, thereby keeping attention on pro- WRIGHT,K.D.,&SCOTT, T. B. (1978). The relationship tection rather than on abstinence. of wives’ treatment to the drinking status of alcohol- Hypnosis has been most widely used in the treat- ics. Journal of Studies on Alcohol, 39, 1577–1581. ment of NICOTINE dependence, and although the YALOM,I.D.,ET AL., (1978). Alcoholics in interactional results vary, a number of large-scale studies indi- group therapy. Archives of General Psychiatry, 35, cate that even a single session of training in self- 419–425. hypnosis can result in complete abstinence of six months or more by approximately one out of four EDWARD KAUFMAN smokers. There are fewer systematic data regarding use of hypnosis with COCAINE,OPIATE, or alcohol addic- Hypnosis Hypnosis is a normal state of attention. The success of the approach is complicated by tive, focused concentration with a relative suspen- the fact that the acute effects of substance intoxica- sion of peripheral awareness, a shift in attention tion and/or the chronic effects on cognitive func- mechanisms in the direction of focus at the expense tion of alcohol and other drug abuse hampers hyp- of the periphery. Being hypnotized is something notic responsiveness, thereby diminishing the like looking through a telephoto lens. What is seen, potential of addicted individuals to enter this state is seen in great detail, but at the expense of context. and benefit from it. Nonetheless, there may be The use of hypnosis has been associated with in- occasional individuals who are sufficiently hyp- ducing a state of relaxation and comfort, with en- notizable and motivated to use this approach as an hanced ability to attend to a therapeutic task, with adjunct to other treatment, diminishing the the capacity to reduce pain and anxiety, and with dysphoria and discomfort that can accompany heightened control over somatic function. For these WITHDRAWAL and abstinence while enhancing and reasons, hypnosis has been used with some benefit supporting their commitment to a behavior change. as an adjunct to the treatment of certain kinds of Hypnosis can be used by licensed and trained phy- DRUG and ALCOHOL ABUSE and ADDICTION. sicians, psychologists, dentists, and other health- Therapeutic approaches involving hypnosis incare professionals who have special training in its clude using it as a substitute for the pleasure-in- use. The treatment is employed in offices and cli- ducing substance, taking a few minutes to induce a nics as well as in hospital settings. It should always self-hypnotic state of relaxation (for example, by be used as an adjunct to a broader treatment strat- imaging oneself floating in a bathtub or a lake, or egy. visualizing pleasant surroundings on an imaginary Hypnosis is a naturally occurring mental state screen). In this strategy the hypnosis is a safe sub- that can be tapped in a matter of seconds and stitute for the pleasure-inducing effects of the drug. mobilized as a means of enhancing control over A second approach involves ego-enhancing tech- behavior, as well as the effects of withdrawal and niques, providing the subject with encouragement, abstinence, in motivated patients supervised by ap- picturing himself or herself living well without the propriately trained professionals. TREATMENT TYPES: Long-term Versus Brief 1243

BIBLIOGRAPHY how much the better outcomes should be attributed to longer stays in treatment or to individual charac- CHILDRESS, A. R. Et al. (1994). Can induced moods trig- teristics such as motivation and initial success in ger drug-related responses in opiate abuse patients? treatment. The most direct way to untangle treat- Journal of Substance Abuse Treatment 11, ment from motivation effects is to conduct studies 17&endash;23. in which patients are randomized to different HAXBY, D. G. (1995). Treatment of nicotine dependence. lengths or intensities of treatment, and their out- American Journal of Health Systems Pharmacists 52, comes examined over time. Studies of this sort have 265&endash;281. produced very little evidence to indicate that longer ORMAN, D. J. (1991). Reframing of an addiction via or more intense treatments produce better sub- hypnotherapy: a case presentation. American Journal stance-abuse outcomes than shorter or less intense of Clinical Hypnosis 33, 263&endash;271. treatments. For example, a recent random assign- PAGE, R. A., & HANDLEY, G. W. (1993). The use of hyp- ment study compared 6- and 12-month therapeutic nosis in cocaine addiction. American Journal of Clini- community programs, and 3- and 6-month resi- cal Hypnosis 36, 120&endash;123. dential programs with a relapse prevention focus. STOIL, M. J. (1989). Problems in the evaluation of hyp- In both cases, the long and short versions of the nosis in the treatment of alcoholism. Journal of Sub- same program did not differ in rates or patterns of stance Abuse Treatment 6, 31&endash;35. drug use during six-month posttreatment followup VALBO, A., & EIDE, T. (1996). Smoking cessation in periods. This suggests that the relationship between pregnancy: the effect of hypnosis in a randomized longer treatments and better outcomes is probably study. Addictive Behavior 21, 29&endash;35. more a function of motivation and other patient DAVID SPIEGEL characteristics than duration of treatment received. However, it should also be stressed that many substance abuse treatment programs feature a con- Long-term Versus Brief For many medical tinuum of care, in which patients spend a certain and psychiatric disorders that, like substance use amount of time in an initial higher intensity treat- disorders, have a chronic course, longer-term treatment and then ‘‘step down’’ to a lower intensity ments are usually found to be much more effective level of care, such as aftercare. Perhaps participa- than short interventions. For example, most pation in and completion of aftercare following initial tients with disorders such as hypertension, elevated treatment has greater prognostic significance than cholesterol, diabetes, or schizophrenia have the the duration of a single level of care? Surprisingly, best clinical course if they maintain lifestyle modi- research suggests it does not. In the majority of the fications and remain on their medications for ex- relatively few studies that have examined this issue, tended periods of time. One would therefore think patients who were randomly assigned to active af- that individuals with substance use disorders who tercare treatments did not have better substance seek treatment would have better outcomes if they use outcomes than those who were randomized to received longer, as opposed to shorter, episodes of either no aftercare or minimal aftercare conditions. care. However, research findings in the addictions Is it therefore the case that duration of substance have indicated that the relationship between length use treatment, whether in one level of care or a of treatment and outcome is not particularly continuum of care, is not related to substance use straightforward. outcome? Despite the results from randomized There is considerable evidence that patients who studies described here, duration might still be of stay in treatment longer have better outcomes. some importance. For example, monitoring sub- That is, when patients with similar demographic stance abusers with low-cost, low-intensity inter- characteristics and pretreatment substance-use se- ventions over long periods of time and arranging verity all enter the same treatment program, those for more intensive treatments if they appear to have who stay in treatment longer will on average have resumed use or be at risk might produce better better treatment outcomes that those who leave outcomes than simply discharging patients follow- early. The dividing line that predicts good versus ing an initial episode of care and maintaining no poor outcome has frequently been retention for at contact after that. However, this approach has yet least 90 days in treatment. However, it is not clear to be evaluated in controlled research studies. 1244 TREATMENT TYPES: Minnesota Model

Although the research literature does not nesota Model was the blending of professional strongly support the use of longer-term treatment behavioral science understandings with AA’s prin- interventions, there is consensus among clinicians ciples. Important in the development of the Minne- and clinical researchers that sustained recoveries sota Model is the way treatment procedures from substance use disorders generally require on- emerged from listening to alcoholics, from trial and going efforts by those who have these disorders. error, from acknowledgment of the mutual help Some of the behaviors that have been associated approach of AA, and from the use of elementary with good long-term outcomes include regular at- assumptions rather than either a well-developed tendance at self-help groups such as Alcoholics theoretical position or a generally accepted thera- Anonymous, treatment for family or marital prob- peutic protocol. In many ways, the Minnesota lems, employment, involvement with religion, and Model may be seen as having come about in a commitment to new interests or hobbies. These grassroots, pragmatic manner. findings are consistent with the notion that formal Because of its evolutionary, noncentralized de- treatment, whether of short or long duration, is velopment, the Minnesota Model is not a standard- useful for beginning a process of change that must ized set of procedures but an approach organized be sustained over long periods of time in order to be around a shared set of assumptions. These assump- successful and that ultimately involves many areas tions have been articulated by Dan Anderson, the of functioning. former president of Hazelden Foundation and one of the early professionals working with the Minne- sota Model at Wilmar State Hospital. They are the BIBLIOGRAPHY following: (1) Alcoholism exists in a consolidation MCCUSKER, J., ET AL. (1995). The effectiveness of alter- of symptoms; (2) alcoholism is an illness character- native planned durations of residential drug abuse ized by an inability to determine time, frequency, treatment. American Journal of Public Health, 85, or quantity of consumption; (3) alcoholism is non- 1426-1429. volitional—alcoholics should not be blamed for MCKAY, J. R. (in press). The role of continuing care in their inability to drink ethanol (alcohol); outpatient alcohol treatment programs. In M. (4) alcoholism is a physical, psychological, social, Galanter (Ed.), Recent developments in alcoholism, and spiritual illness; and (5) alcoholism is a chronic vol XV: Services research in the era of managed care. primary illness—meaning, that once manifest, a New York: Plenum. return to nonproblem drinking is not possible. Al- MOOS, R. H., ET AL. (1990). Alcoholism treatment: Con- though these assumptions are phrased as pertain- text, process, and outcome. New York: Oxford Uni- ing to alcoholism, early experience with the Minne- versity Press. sota Model demonstrated that drug abuse other SIMPSON,D.D.,ET AL. (1997). Treatment retention and than alcoholism can also be understood and treated follow-up outcomes in the Drug Abuse Treatment within these assumptions. Chemical dependency is Outcome Study (DATOS). Psychology of Addictive the term generally used by clients and treatment Behaviors, 11, 4, 294-307. providers when referring to substance abuse. The Minnesota Model provides treatment for chemical JAMES R. MCKAY dependency—for both alcohol and other drugs. A twenty-four to twenty-eight day inpatient treatment stay, or approximately eighty-five hours Minnesota Model Origins of the Minnesota in outpatient rehabilitation, characterizes the Min- Model of drug abuse treatment are found in three nesota Model treatment. Inpatient treatment may independent Minnesota treatment programs: Pio- occur in hospital settings or free-standing facilities neer House in 1948, Hazelden in 1949, and and may be run by for-profit or nonprofit organiza- Wilmar State Hospital in 1950. The Hazelden Cli- tions. Different treatment settings have different nics are still in existence and are located in Minne- mixes of staff positions, but the multidisciplinary sota and Florida. The original treatment programs team of medical and psychological professionals recognized ALCOHOLICS ANONYMOUS (AA) as hav- plus clergy and focal counselors are frequently ing success in bringing about recovery from found—either in a close interacting network or a ALCOHOLISM. Unique to this early stage of the Min- more diffuse working arrangement. TREATMENT TYPES: Minnesota Model 1245

Primary focal counselors have either received chemical dependency. Their behavior has been di- specific training in the Minnesota Model approach rected by the disease, but they have been unable to to treatment or have learned their counseling skills see the reality of their behavior and the conse- in an apprenticelike placement. Most counselors quences because of the disease characteristic of are neither mental-health-degreed professionals denial. Treatment plans are individualized based nor holders of medically related degrees, but they on assessments by the multidisciplinary staff. Gen- are commonly working on their own twelve-step erally, the first goal of treatment is to break the programs because of life experience with chemical client’s denial and the second goal is for the client dependency or other addictions. As in AA, this to accept the disease concept. Because treatment shared personal experience of both clients and has clients ranging from new admissions to those counselors is important for the client/counselor re- ready to complete their program, senior peers are lationship and the behavior modeling the counselor very influential in helping clients who are in the provides for the client. early stages of treatment to understand denial and Minnesota Model treatment programs vary in the DISEASE CONCEPT. the centrality of counseling staff and the pro- Acceptance and awareness that they are able to grammed autonomy of the treatment experience. change if they take appropriate action to deal with Some treatment programs have the counselor facil- their chronic condition is the message in the final itating the majority of the groups and visibly di- treatment stage. The rehabilitation staff develops recting the treatment experience. Other programs an aftercare plan with the client that will continue have the treatment groups carrying out the treat- to support some of the changes that have taken ment experience where the activity follows a pre- place during treatment and it encourages changes scribed format, but the group members are the that will promote ongoing recovery. Characteristi- visible actors while the counseling staff maintains a cally, clients comment on their increased awareness low profile as they seek to empower clients to ac- of simple pleasures and being with other people quire the insights and resources necessary for their without trying to manipulate them. They are told recovery. Treatment also varies in the amount of that they must continue to work the AA steps, at- confrontation, the presence of a family program tend AA meetings, and address other problems of requirement, the extent of assigned reading, the living if they are going to experience recovery be- detail of client record documentation, and other cause primary treatment is just one part of an on- attributes. going continuum of care. Recovery is hard work What Minnesota Model treatment has without made even more difficult by possible bouts of de- exception is the use of AA principles and under- pression, problems of regaining trust from their standings (steps and traditions) as primary ad- family, and establishing new friends and activities juncts in the treatment experience. Clients are pro- not tied to alcohol and drug use. videdwiththeAA‘‘BigBook’’(Alcoholics Treatment outcome studies carried out by Ha- Anonymous) and The TWELVE STEPS and Twelve zelden for their treatment clients and for ten treat- Traditions. Both of these books are required read- ment programs in the Hazelden Evaluation Con- ing. Spirituality is emphasized as important to re- sortium are in general agreement with outcome covery, which is consistent with the AA under- evaluation findings reported by Comprehensive As- standing. AA group meetings occur in the schedule sessment and Treatment Outcome Research for ap- of rehabilitation activities, and clients may visit a proximately one hundred hospital and freestanding community AA meeting as part of their treatment treatment programs throughout the United States. experience. Clients will work on AA steps during About 50 percent of all clients treated, including their treatment experience; some programs focus noncompleters, are abstinent for one year following on the first five steps while others emphasize all treatment discharge. This percentage is higher for twelve steps. treatment completers and for clients having fewer Treatment it not just an intensive exposure to complications and more stability in their lives. AA. It motivates treatment participants to develop Thirty-three percent of the clients have returned to mutual trust and to share and be open about how heavy use patterns within the year, and the remain- the use of chemicals has come to control their der have had slips or a period of resumed drinking/ lives. Clients are told that they have the disease of use but also have sustained periods of abstinence. 1246 TREATMENT TYPES: Non-Medical Detoxification

Abstinent clients have fewer legal, health, interper- the problems associated with each are quite differ- sonal, and job-related problems, and about 75 per- ent and require different methods to tackle them. cent attend AA and/or continuing care. In relation to Western society’s favorite drug, alco- The Minnesota Model is a label that is applied to hol, these problems are so common that the chal- a broad range of programming. Nevertheless, it lenge is to develop methods which can be widely represents a highly visible treatment modality ser- used without excessive cost. This requirement tends ving a large number of clients throughout the to rule out an exclusive reliance on expensive medi- United States, although it is more dominant in cal settings, medical personnel and medication— certain regions. It has a counterpart known as the even though both problems carry with them a small Icelandic Model, and both of these treatment but significant risk of death or serious injury. De- models have influenced treatment in SWEDEN and spite this restriction, human ingenuity has devised other parts of Scandinavia. International interest in a number of relatively safe and cost-effective alter- adopting the Minnesota Model appears to be grow- natives to hospital care and which are frequently ing, with scattered treatment programs appearing preferred by the clients in need of ‘sobering up’ or in many countries. Little research has been done on ‘drying out’. These innovative services have usually the diffusion of this treatment model to other been developed for people who run into problems cultures. with their use of alcohol and have later been emu- lated by services for people who use other dependence-inducing drugs. (SEE ALSO: Alcoholism; Treatment, History of ) The most visible problems associated with extreme intoxication concern public order, particu- BIBLIOGRAPHY larly in relation to the use of alcohol. Drunkenness ANDERSON, D. J. (1981). Perspectives on treatment: The is associated with violence, both to the self and to Minnesota experience. Center City, MN: Hazelden others as well as with ‘public nuisance’ offenses. Educational Services. The habitual drunken offender, who may otherwise COOK, C. C. H. (1988). The Minnesota Model in the be quite harmless, and the potentially dangerous management of drug and alcohol dependency: Mira- disorderly ‘drunk’ present themselves in huge num- cle, method or myth? Part I. The philosophy and bers to police forces the world over and, typically, programme. British Journal of Addiction, 83, 625– then clog up already overburdened court and penal 634. systems. In the past two decades several countries COOK, C. C. H. (1988). The Minnesota Model in the have experimented with having drunkenness management of drug and alcohol dependency: Mira- ‘decriminalized’ i.e. made no longer a criminal of- cle, method or myth? Part II. Evidence and conclu- fense. The aim of this has been to free up the courts sions. British Journal of Addiction, 83, 735–748. and the police so that they can concentrate on more LAUNDERGAN, J. C. (1982). Easy does it: Alcoholism serious crimes. Another impetus for decriminaliza- treatment outcomes, Hazelden and the Minnesota tion of drunkenness has been a growing awareness Model. Center City, MN: Hazelden Educational Ser- that locking up drunk people in police cells puts vices. them at risk of serious harm. In Australia, for example, the tragic deaths of many Aboriginal people J. CLARK LAUNDERGAN while in police custody are thought to have been caused by the combined effects of alcohol and confinement. Non-Medical Detoxification The term Historically, the setting up of non-medical de- ‘detoxification’ is used to refer to the management toxification services occurred hand-in-hand with of two distinct types of problem resulting from the decriminalization of drunkenness. Among the excessive alcohol or other drug use. These are the first experiments in the 1970s were by the Addic- symptoms and behavioral changes associated with tion Research Foundation in the Canadian province extreme intoxication on the one hand and of with- of Ontario and St. Vincents’ Hospital in New South drawal following extended use on the other. Al- Wales, Australia. In both cases, services were though both involve recovering from the toxic ef- set-up with the principal aim of diverting drunken- fects of a drug while refraining from further use, ness offenders from the criminal justice system to a TREATMENT TYPES: Non-Medical Detoxification 1247 more humane setting where they might be also be It should be noted that there are also potentially counseled to seek help for their drinking problems. serious medical emergencies associated with ex- Both utilized a residential social setting staffed by treme levels of drug intoxication. Poisoning non-medical personnel and provided no medical through overdose, accidental or otherwise, is a care or medication. To this day they successfully common cause of admission to hospital emergency supervise thousands of problem drinkers, mainly rooms the world over and all too frequently this self-referred, through sobering-up and/or alcohol may result in death. The most common of such withdrawal with an impressive record of safety. For instances are deliberate acts of self-poisoning, usu- example, in its first ten years of operation, the New ally with prescribed medication, closely followed by South Wales facility has dealt with nearly 14,000 cases of accidental alcohol poisoning. Over-dosing admissions and recorded only two fatalities among on heroin can also be quite common where that this high-risk population. Only 1 percent have re- drug is widely used—especially as a result of users quired transfer to a nearby hospital for specialized having lost tolerance to the drug’s effects after a medical care, often for reasons unrelated to alcohol period of abstinence, if used with other CNS de- withdrawal. These facilities have not been success- pressant drugs such as alcohol or benzodiazepines ful, however, in terms of attracting referrals from and/or if the heroin is unusually pure. It is for this the police. In New South Wales, for example, the reason that the staff of sobering up shelters, or of police have accounted for only 0.2 percent of refer- any facility which also caters for drug users, should rals. It is possible that these facilities are diverting be trained to identify the warning signs of overdose some potential offenders before they come to police so that the sufferer may be taken to hospital with as attention, although this does not appear to be to a little delay as possible. In some countries the opi- very significant extent. ate-antagonist drug Narcan is used in a variety of non-medical settings including by drug using peers at the scene of an overdose (Lenton and SOBERING-UP SHELTERS Hargreaves, in press). Similarly, there is a great In an excellent review of detoxification services educational need among the general drug-using worldwide, Orford and Wawman (1986) suggest and drinking public who all too often abandon that the design of the above services confused the their friends to ‘sleep it off’ and later find them problems of intoxication and withdrawal. They asphyxiated. should be seen as highly successful and cost-effective alternatives to hospital care for alcohol with- DEALINGWITH ALCOHOL AND drawal but not the solution for what society should OTHER DRUGWITHDRAWAL do with the habitual drunken offender. Australia’s Since the pioneering Canadian and Australian continuing concern to prevent Aboriginal deaths in development of ‘social setting’ detoxification ser- custody has also prompted an increasing use of vices to assist people safely through alcohol with- what have come to be called ‘sobering up shelters’. drawal, a variety of other non-medical approaches These provide supportive non-medical settings have been developed. Really, detoxification services where people can stay a few hours or, if necessary, should be seen as being on a continuum ranging overnight until, literally, they have sobered up. from supervision by an informed ‘lay person’—a They have been found to provide an inexpensive relative, a recovered problem drinker or user or alternative to prison and have succeeded in gaining non-medical professionals—all the way to 24 hour the necessary support of the local police. Experi- nursing and medical care in a specialist hospital ence to date suggests that close liaison between unit. Even in the latter case substantial variations shelter staff and police officers is necessary so that exist regarding the amount of medication used dur- all concerned are clear about the specific aims of ing withdrawal—or even whether any medication the project and how each can help the other. It is is used at all. Detoxification services designed to important that specialist treatment facilities are minimize discomfort and the possibility of actual available to the sobering-up shelters so that people harm occurring during withdrawal may be ‘non- requiring urgent medical attention or longer-term medical’ in several senses: by, variously, using non- help with a drinking problem can be referred on. medical settings (e.g. hostels, the client’s home), 1248 TREATMENT TYPES: Non-Medical Detoxification non-medical personnel (e.g. relatives, ex-problem psychiatric hospital or specialized treatment unit. drinkers) or non-medical procedures. There is wide Later studies have found evidence that home de- consensus that medical assistance needs to be avail- toxification is more acceptable to groups that are able if required but the responsibility for accessing frequently under-represented in traditional set- this need not be left only with medical personnel. tings such as the young, the elderly and women. The Ontario model of non-medical detoxifica- Home detoxification therefore offered a safe alter- tion was created following the results of a study native to completely unsupervised withdrawal on reported in 1970. It found in the relative safety of the one hand and a cost-effective alternative to an alcoholism treatment unit that only 5 percent of inpatient hospital care. The cost of Home Detoxifi- admissions required any form of medical assis- cation per client has been estimated to be approxi- tance. In addition to the residential ‘social setting’ mately a quarter that of inpatient hospital care. model of detoxification, ‘ambulatory’ or outpatient Formal evaluations of the UK service suggest that detoxification procedures were developed which re- not only is there no loss in terms of either safety or lied on the drinker calling in daily to a clinic to efficacy but that the clients prefer to be treated at collect their medication and receive a brief home and that many would refuse to attend a hos- check-up. Evaluations of these types of service con- pital facility. ducted in several countries have demonstrated that their success rate in terms of both safety and effec- CONCLUSIONS tiveness is at least the equal of inpatient care—and is considerably cheaper. Non-medical detoxification services have been A variation of this approach is ‘home detoxifi- developed to cope with the problems associated cation’, an approach developed initially in the UK with alcohol withdrawal in chronic heavy drinkers with problem drinkers and now widely used in and also with episodes of alcohol-induced intoxica- many other countries. This usually involves a com- tion. While such services are being developed for munity alcohol worker (e.g. nurse, counselor or users of other mood-altering drugs, there is, as yet, psychologist) assisting a family practitioner to as- only limited published research concerning their sess a drinker who wishes to stop drinking alcohol efficacy. Non-medical detoxification services need but who may experience severe withdrawal symp- clear aims and objectives and should be part of a toms in the process. Providing the home environ- comprehensive range services for people with alco- ment is deemed to be supportive and the client hol problems. Both intoxication and alcohol with- sufficiently motivated to stop drinking the detoxi- drawal are so common in Western society that, fication then occurs in the patient’s home with although they carry a small but significant risk of supportive visits from the alcohol worker. The serious injury or death, it is too costly to attempt to family doctor’s telephone number is provided to provide specialist medical care in every instance. the client and any close relative or partner in case Safe and inexpensive alternatives have been devel- of emergency. A particular effort is made to screen oped in a number of countries, which are to be out drinkers with a history of withdrawal fits, recommended over a laissez-faire or punitive ap- delerium tremens or Korsakoff’s Psychosis. In or- proach to these major social problems. There is der to reduce the real risk of overdose with some encouraging evidence that community-based de- types of medication (notably chlormethiazole) ei- toxification services attract problem drinkers who ther the alcohol worker or a relative holds the are usually under-estimated in treatment services, medication. An important reason for developing such as women, young people and the elderly. this service in the UK was the discovery that many family doctors were already prescribing BIBLIOGRAPHY chlormethiazole to cover alcohol withdrawal but in the absence of any supervision and frequently ANNIS, H. (1985) Is Inpatient Rehabilitation of the Alco- longer than the recommended maximum period— holic Cost Effective? Advances in Alcohol and Sub- sometimes even indefinitely. It was found that this stance Abuse, 5, 175–190. was the single most common method of managing BENNIE, C. (1998) A comparison of home detoxicfication alcohol withdrawal among a group of patients and minimal intervention strategies for problem who, for many reasons, were loathe to attend a drinkers. Alcohol and Alcoholism, 33, 2, 157–163. TREATMENT TYPES: Outpatient Versus Inpatient 1249

COOPER, D. (1994) Home Detoxification and Assessment, two studies a day hospital outpatient treatment was Radcliffe Medical Press, Oxford, UK. more effective. In the studies that found inpatient FLEMAN, N. (1997) Alcohol home detoxification: a litera- treatment to be more effective, patients in the com- ture review. Alcohol and Alcoholism, 32, 6, 649–656. parative outpatient programs were less likely to LENTON, S. and HARGREAVES, K. (2000). Editorial: A receive an initial period of inpatient DETOXIFICA- trial of naloxone for peer administration has merit, TION and these studies were slightly less likely than but will the lawyers let it happen? Drug and Alcohol those finding no treatment differences to randomly Review. [In Press] assign patients to treatment. Unless subjects are LENTON, S. and HARGREAVES, K. (2000). Should we trial randomly assigned to each of the treatments, no the provision of naloxone to heroin users for peer way exists of knowing whether the findings were administration to prevent fatal overdose?—For De- due to different kinds of patients volunteering for bate. Medical Journal of Australia. [In Press] the different types of treatment. On the other hand, MIDFORD, R., DALY, A. and HOLMES, M. (1994) The care it could be argued that random assignment is an of public drunks in Halls Creek: A model for commu- artificial selection process that makes it difficult to nity involvement. Health Promotion Journal of Aus- generalize findings to ‘‘real life’’ situation. Among tralia, 4(19):5–8. the studies that compared costs, treatment in out- ORFORD,J.&WAWMAN, T. (1986) Alcohol Detoxification patient settings was less expensive than treatment Services: a Review. London: DHSS, HMSO. in inpatient settings. Overall, the investigators con- PEDERSON, C. (1986) Hospital admissions from a non- cluded that there were no differences between in- medical alcohol detoxification unit, Drug and Alcohol patient and outpatient treatments. However, par- Review, 5; 133–137. ticular types of patients (e.g., those with medical/ STOCKWELL, T., BOLT,E.&HOOPER, J. (1986) Detoxifi- psychiatric impairments) may benefit more from cation from alcohol at home managed by General inpatient treatment. Practitioners. British Medical Journal 292, 733–735. STOCKWELL, T., BOLT, E., MILNER,I.ET AL. (1991) Home COCAINE TREATMENT Detoxification for Problem Drinkers: It’s safety and Alterman et al. (1994) found that a twenty- efficacy in comparison with inpatient care. Alcohol seven hour per week day hospital treatment was and Alcoholism 26(2), 207–214. just as effective as more costly inpatient treatment TIM STOCKWELL for low SES male veterans. Both groups showed significant improvements in functioning at the seven-month follow-up evaluation. Although a Outpatient Versus Inpatient With the ris- greater proportion of subject assigned to inpatient ing cost of drug treatment and the growth of man- treatment completed treatment, the day hospital aged care, outpatient treatment is becoming a treatment costs were 40 to 60 percent of inpatient much more common form of treatment for sub- treatment. Another randomized clinical trial com- stance abuse than inpatient treatment. Recent re- paring day and residential treatment programs for views of the scientific literature have supported this drug abuse (mostly COCAINE) found no overall dif- trend by showing that there is no strong evidence ferences in substance use problems between the two for the superiority of inpatient over less costly out- treatment conditions (Guydish et al.,1998). patient treatment. In fact, more recent investiga- Comparing Outpatient Treatment Intensi- tions have focused on comparing various levels of ties. As a result of finding no superior effect of intensities of outpatient treatment. inpatient treatment and given the limited availability of inpatient care, researchers are now comparing various intensities of outpatient treatment. ALCOHOL TREATMENT Coviello et al. (in press) found no differences be- Finney et al. (1996) reviewed fourteen studies of tween male veterans randomly assigned to either a ALCOHOL abuse and found that seven showed no 12 hour per week day hospital program or a six significant differences in drinking outcomes be- hour per week outpatient program for cocaine de- tween inpatient and outpatient treatment, five pendence. Both treatments were similar in thera- showed inpatient treatment to be superior, and in peutic structure and only differed in level of treat- 1250 TREATMENT TYPES: Pharmacotherapy, An Overview

ment intensity. McLellan et al. (1997) found no day hospital cocaine rehabilitation. Journal of Ner- differences between intensive outpatient programs vous and Mental Diseases, 182(3), 157–163. of at least three sessions per week and traditional AVANTS,S.K.,MARGOLIN,A.,SINDELAR,J.L., outpatient programs of one or two sessions weekly. ROUNSAVILLE, B. J., SCHOTTENFELD, R., STINE, S., In addition, Avants and colleagues (1999) have COONEY, N. L., ROSENHECK, R. A., LI, S. H., KOSTEN, demonstrated that providing enhanced standard T. R. (1999). Day treatment versus enhanced stan- care for OPIATE-dependent patients enrolled in dard methadone services for opioid-dependent pa- METHADONE maintenance treatment may be just as tients: A comparison of clinical efficacy and cost. effective and less costly than intensive day treat- American Journal of Psychiatry, 156(1), 27–33. ment. COVIELLO, D. M., ALTERMAN, A. I., RUTHERFORD, M. J., CACCIOLA, J. S., MCKAY, J. R., ZANIS, D. A., (in press). The effectiveness of two intensities of psychosocial CONCLUSIONS treatment for cocaine dependence. Drug and Alcohol Research suggests that there are few differences Dependence. between inpatient and outpatient treatment for FINNEY, J. W., HAHN, A. C., MOOS, R. H. (1996). The substance abuse. Both treatments result in im- effectiveness of inpatient and outpatient treatment for provements in patient functioning. While inpatient alcohol abuse: The need to focus on mediators and treatment is more effective in retaining patients in moderators of setting effects. Addictions, 91(12), treatment, it is much more costly than outpatient 1773–1796. treatment. However, initial short-term inpatient GUYDISH, J., WERDEGAR, D., SORENSEN, J. L., CLARK, W., treatment in the form of detoxification may be ACAMPORA, A. (1998). Drug abuse day treatment: A necessary to increase positive outcomes of later randomized clinical trial comparing day and residen- outpatient care. Recently, much more attention is tial treatment programs. Journal of Consulting and being directed toward studying various levels of Clinical Psychology, 66(2), 280–289. intensities of outpatient programs. Preliminary MCLELLAN, A. T., HAGAN, T. A., MEYERS, K., RANDALL, findings suggest that lower intensity outpatients M., DURRELL, J. (1997). ‘‘Intensive’’ outpatient sub- treatments may be just as effective as similar higher stance abuse treatment: Comparisons with ‘‘tradi- intensity treatments. What seems to be more im- tional’’ outpatient treatment. Journal of Addictive portant is the content of the intervention rather Diseases, 16, 57–84. than the setting in which the treatment is provided. ARTHUR I. ALTERMAN It should be noted that inpatient treatment is REVISEDBY DONNA M. COVIELLO clearly indicated for patients with acute medical and psychiatric problems that can only be handled in an inpatient setting. Inpatient treatment may Pharmacotherapy, An Overview Phar- also be necessary for patients who continually fail macological agents may be used for several pur- in outpatient treatment, have few social sources, or poses in the treatment of drug and alcohol addic- whose recovery would be jeopardized in an outpa- tion. These include the alleviation of acute with- tient program due to exposure to a social environ- drawal symptoms, the prevention of relapse to drug ment where substance use is prevalent. As a final or alcohol use, and the blocking of the euphorigenic cautionary note, much of the research in this area effects of drugs of abuse. The various medications has been conducted with adult male clients. More are used in the treatment of addiction to alcohol, research is needed with women and adolescent opiates, cocaine, tobacco, and sedatives. populations. ALCOHOLISM BIBLIOGRAPHY Detoxification. The use and abuse of ALCO- ALTERMAN, A. I., O’BRIEN, C. P., MCLELLAN, A. T., AU- HOL has been known to humankind for centuries, GUST, D. S., SNIDER, E. C., DROBA, M., CORNISH, J. W., and alcohol is currently one of the most widely used HALL, C. P., RAPHAELSON, A. H., and SCHRADE,F.X. of the mood-altering substances. Habitual alcohol (1994). Effectiveness and costs of inpatient versus use is associated with the development of TOLER- TREATMENT TYPES: Pharmacotherapy, An Overview 1251

ANCE and physiological (PHYSICAL)DEPENDENCE. but it may be beneficial in the treatment of other Tolerance refers to a decrease in susceptibility to psychiatric disorders. It has received much atten- the effects of alcohol following chronic alcohol use, tion in the investigation of pharmacologic agents which results in the user consuming increasing for the treatment of alcohol dependence, and sev- amounts of alcohol over time. Physical dependence eral studies have reported that its use had favorable may be conceptualized as a physiological state in effects on alcohol consumption. For example, after which the recurrent administration of alcohol is receiving doses of lithium comparable to those ad- required to prevent the onset of withdrawal symp- ministered to human beings, laboratory animals toms. Symptoms of alcohol withdrawal include irri- demonstrated a significant reduction in alcohol tability, tremulousness, anxiety, sweating, chills, consumption. In recovering alcoholics, lithium fluctuations in pulse and blood pressure, diarrhea, treatment has been associated with a decreased de- and, in severe cases, seizure. These symptoms gen- sire to continue drinking after alcohol use and, in erally begin within twenty-four hours following the several studies, with a higher rate of abstinence for last use of alcohol, peak within forty-eight hours, those alcoholic patients who were compliant with and subside over several days. therapy. Although these small studies on the effi- Pharmacotherapy for alcohol withdrawal in- cacy of lithium for alcohol dependence appeared cludes the use of agents, such as BENZODIAZEPINES promising, a recent large placebo-controlled study and BARBITURATES, that are cross-tolerant with al- failed to demonstrate a beneficial effect of lithium. cohol. These agents attenuate the symptoms of At the present time, although lithium certainly has withdrawal and result in decreased arousal, agita- a place in the treatment of alcoholic patients with tion, and potential for seizure development. Medi- bipolar disorder, the indications for its use in other cation is provided in doses that are sufficient to patients with alcohol dependence are less clear. produce mild sedation and physiological stabiliza- Antidepressants. Depressive symptoms are tion early in the withdrawal period; this is followed noted in many alcoholics at the time that they enter by a gradual dose reduction and then dis- treatment. Because of the frequent co-occurrence of continuation over the next one to two weeks. Cur- depression and alcoholism, the use of antidepres- rently, benzodiazepines are the agents of choice for sants would appear to be potentially useful in this the treatment of alcohol withdrawal, because of the population. Several studies have demonstrated fa- relatively high therapeutic safety index of these vorable effects of antidepressants on alcohol con- medications, their ability to be administered both sumption. Tricyclic antidepressants such as imip- orally and intravenously, and because of their anti- ramine and desipramine inhibit the re-uptake of convulsant properties. Barbiturates may be used in norepinephrine and serotonin in nerve terminals. a similar fashion, but they have a lower therapeutic These medications have been associated with de- index of safety than do benzodiazepines. creased ethanol consumption in laboratory animals Recent additions to the pharmacotherapy of al- and in human alcoholic subjects. The serotonin cohol withdrawal include clonidine and carbamaz- reuptake inhibitors (blockers) zimelidine, epine. Clonidine is an antihypertensive agent (i.e., viqualine, fluvoxamine, and fluoxetine (Prozac) it lowers blood pressure) that has recently been have also demonstrated favorable short-term re- used in the treatment of drug withdrawal states and sults in the treatment of alcohol dependence. Al- chronic pain. This medication decreses autonomic though these medications are not routinely admin- hyperactivity (i.e., it lowers an increased pulse and istered to all recovering alcoholics, many blood pressure), but it does not have the anticon- physicians consider the use of antidepressants in vulsant properties of the benzodiazepines or barbi- alcoholic patients if depressive symptoms do not turates. Carbamazepine has also been employed in resolve after several weeks of abstinence, or if a the treatment of alcohol withdrawal and does have mood disorder was present prior to the onset of anticonvulsant properties. Neither medication is ethanol abuse. habit forming and thus may have potential in the Anxiolytics. Used to decrease anxiety, treatment of alcohol withdrawal. anxiolyrics include benzodiazepines, such as Maintenance Lithium. Lithium is primarily chlordiazepoxide (Librium) and diazepam (Val- employed in the treatment of bipolar mood disor- ium), and azaspirodecadiones, such as buspirone. der (previously termed manic-depressive disorder), Both classes of medication have been investigated 1252 TREATMENT TYPES: Pharmacotherapy, An Overview for use in alcohol dependence. Early studies sup- accumulation of acetaldehyde following the con- ported the use of benzodiazepines in recovering sumption of alcohol. Acetaldehyde levels accumu- alcoholics with claims of decreased alcohol craving late if patients who are receiving disulfiram ingest and consumption after chlordiazepoxide adminis- alcohol, with the result that the patients may expe- tration. Other controlled trials refuted this, how- rience symptoms of acetaldehyde toxicity. These ever, and many physicians would question the use include sweating, chest pain, palpitations, flushing, of benzodiazepines in this population. The thirst, nausea, vomiting, headache, difficulty azaspirodecadiones such as buspirone are nonad- breathing, hypotension, dizziness, weakness, blur- dictive medications that have been marketed for red vision, and confusion. Symptoms may begin the treatment of anxiety. Although few controlled within five to fifteen minutes following alcohol in- trials have been conducted that evaluated the effect gestion and may last from thirty minutes to several of buspirone on human alcohol use, animal studies hours. The use of disulfiram is based upon the have demonstrated decreased alcohol consumption premise that the fear or actual experience of this after treatment with this agent. Unlike benzodiaze- adverse event may serve as a deterrent to alcohol pines, buspirone is not known to be habit forming use. Despite its toxicity, disulfiram has been used and thus may be a promising agent for additional safely by thousands of recovering alcoholics since controlled studies in human subjects. its introduction in 1948. Supervised voluntary use Dopaminergic Agents. The effects of dopa- of the medication as an adjunct to other rehabilita- minergic agents on the consumption of alcohol in tive therapy has resulted in reduced alcohol con- animal studies have been conflicting, since both sumption and decreased alcohol-related criminal agents that augment dopaminergic activity and behavior among alcohol-dependent patients. those that diminish it have been noted to decrease Compliance is the key to successful use of di- alcohol consumption. In humans, controlled stud- sulfiram in alcohol dependence, since patients need ies with apomorphine and bromocriptine, both of only discontinue using disulfiram if they wish to which increase dopaminergic activity, have re- resume drinking. Indeed, in an unsupervised set- vealed decreases in alcohol craving, anxiety, and ting, disulfiram administration shows no superior- depression, and increased abstinence among alco- ity over placebo on outcome measures related to holic depressed patients. alcohol use. Methods that have been investigated to Opioid Antagonists. Opioid antagonists are improve compliance include surgical implants of competitive antagonists of OPIODS at opiate recep- disulfiram, reinforcement by providing a reward tors. They include NALOXONE, which may be used for compliance, and contingency management intramuscularly or intravenously to rapidly reverse techniques. Although surgical implants have met opiate intoxication, and NALTREXONE, which is with little success, the other two methods have prescribed orally to prevent or reverse intoxication demonstrated various degrees of efficacy. from opioids. Unlike opioids, these medications are not habit forming and may have a place in the OPIOID DEPENDENCE treatment of alcohol-dependent patients. A variety of studies have demonstrated a reduction of alcohol The opioids include opiates, drugs derived from consumption or self-administration by experimen- the opium poppy (Papaver somniferum), as well as tal animals treated with these agents. In human those synthesized to produce similar narcotic ef- subjects, naltrexone administered as an adjunct to fects. Opium has been used as a medicinal sub- substance-abuse treatment has resulted in a de- stance for at least 6,000 years. Widespread abuse creased rate of alcohol consumption. In addition, of opiates was noted by the eighteenth century, those patients who did experience a ‘‘slip’’ were less with the smoking of opium in Asia; currently, HER- likely than those who were not treated with naltrex- OIN is a major opiate of abuse in the United States. one to suffer a complete relapse to alcohol use. Pharmacotherapy for opiate dependence may be Antidipsotropics. Antidipsotropics are medi- employed both during the acute withdrawal syn- cations that are used to decrease alcohol consump- drome and later to maintain abstinence from illicit tion by creating an adverse reaction following alco- opioids (e.g., heroin). holuse.TheyincludeDISULFIRAM,CALCIUM Acute Opioid Withdrawal. The syndrome of CARBIMIDE, and Flagyl. Disulfiram use results in an acute withdrawal from opiates varies in regard to TREATMENT TYPES: Pharmacotherapy, An Overview 1253 the opiate of abuse. The time of onset, intensity, with less severe withdrawal symptoms than those and duration of withdrawal symptoms depend on associated with methadone withdrawal. several factors, including the half-life of the drug, Antagonists. Opiate antagonists such as nal- the dose, and the chronicity of use. Heroin is a oxone and naltrexone compete with opiates for relatively short-acting agent; symptoms of with- CNS opioid receptors. Naloxone has a short half- drawal often begin within eight to twelve hours life (two to three hours) and is generally employed after the last use. Early symptoms include craving, on a short-term basis to reverse acute opiate intoxi- anxiety, yawning, tearing, runny nose, restlessness, cation. Naltrexone has a longer duration of action and poor sleep. Symptoms may progress to include (approximately twenty-four hours) and is used as a pupil dilation, irritability, muscle and bone aches, long-term maintenance medication to inhibit eu- piloerection (the goose bumps—thus the term cold phoria in opioid addicts. Both medications have turkey), and hot and cold flashes. Peak severity been used with relative safety for several years, and occurs 48 to 72 hours after the last dose and in- maltrexone has been successfully employed as an cludes nausea and vomiting, diarrhea, low-grade adjunct to other therapies in the treatment of opi- fever, increased blood pressure, pulse, and respira- oid addicts. Clinically, side effects of naltrexone tion, muscle twitching, and occasional jerking of may include mild dysphoria and elevation in corti- the lower extremities (which explains the term sol and beta-endorphin levels; no withdrawal syn- kicking the habit). The opiate withdrawal syndrome has been noted following its discontinuation. drome following chronic heroin use may last seven Naltrexone is generally administered three to four to ten days, but with longer-acting agents such as times a week at an average dose of 50 milligrams METHADONE, a similar constellation of symptoms per day. Despite its advantages, many opioid ad- may occur; they begin later, peak on the third to dicts resist therapy with this medication, and even eighth day, and persist for several weeks. in the most successful of programs, six-month re- A variety of medications may be used in the tention rates may range from only 20 to 30 percent. treatment of acute opiate withdrawal. The most The addition of psychosocial interventions such as common method is to use opiates alone. A dose high counseling and contingency-management pro- enough to stabilize the patient is administered on grams is helpful. When these interventions are the first day and then gradually tapered over one to added, naltrexone has been noted to be particularly two weeks. Generally, long-acting opiates such as effective in selected groups, such as those made up methadone are employed, but any opiate may be of health care professionals, business people, and used. prisoners on work-release programs. Other medications used for opiate withdrawal Methadone Maintenance. Methadone has are CLONIDINE and BUPRENORPHINE. Clonidine is been used as a safe and effective treatment for an alpha-2 adrenergic agonist that is commonly opioid dependence for over twenty years. Heroin employed as an antihypertensive medication. It is addicts easily adapt to using this long-acting opiate active on central nervous system (CNS) locus that possesses all of the physiological characteris- coeruleus neurons in the same areas at which opi- tics of heroin. When taken orally, methadone may ates exert their effects. Clonidine appears most ef- have less abuse potential than heroin, but the onset fective in decreasing symptoms such as elevation of of its CNS effects are slower and its tendency to pulse and blood pressure and may be less effective induce euphoria is generally less than that of intra- in relieving other symptoms of withdrawal. The venous or inhaled heroin. In addition, it has a major side effects of clonidine are orthostatic hypo- longer half-life than heroin and if it is administered tension and sedation. A recent development in the daily, tissue levels accumulate, thereby decreasing pharmacotherapy of opiate withdrawal is rapid de- interdose withdrawal symptoms that may lead to toxification through the combined use of clonidine repeated opiate use. Methadone maintenance may with opiate antagonists such as naltrexone. This be helpful for addicts who have difficulty adjusting treatment may decrease the time required for the to a drug-free lifestyle or for those who have been detoxification process to two to three days. Opiate unsuccessful with other forms of treatment. addicts may be stabilized on buprenorphine, a During maintenance therapy, methadone is ini- mixed opioid agonist/antagonist, with minimal dis- tiated at a low dose and then gradually increased to comfort and then withdrawn over five to seven days higher doses, which are associated with decreased 1254 TREATMENT TYPES: Pharmacotherapy, An Overview opiate craving and secondary illicit opiate use. proaches to substance-abuse treatment, a variety of With methadone maintenance treatment, many pa- pharmacotherapeutic interventions may be of ben- tients show significant decreases in illicit drug use, efit to cocaine abusers. depression, and criminal activity, and they demon- Pharmacotherapy for cocaine abuse may be em- strate increased employment. Therapy that is pro- ployed to address specific symptoms that occur vided for extended periods of time and in the con- during the cocaine-withdrawal syndrome. Gawin text of other psychosocial services has been and Kleber identified three phases in the cocaine associated with the highest success rates. abstinence syndrome. The crash phase generally Another maintenance medication currently un- begins soon after cocaine use ends and may last up der investigation is levo-alpha-acetylmethadol to four days. Symptoms experienced at this time (LAAM). LAAM is a long-acting form of metha- may include depression, suicidal ideation, irritabil- done that requires administration three times per ity, anxiety, and intense cocaine craving. Sedatives week instead of daily as with methadone. Although such as alcohol and heroin may be used by addicts LAAM has been associated with a reduction in to alleviate these symptoms. The second or with- illicit opioid use, its slower onset of action may lead drawal phase may last two to ten weeks and is to decreases in treatment retention compared to the characterized by anxiety, depression, inability to use of methadone. The initiation of treatment with experience pleasure, and increased cocaine craving. methadone and subsequent conversion to LAAM The third or extinction phase may last three to therapy may improve compliance with this medica- twelve months; during this phase, cocaine craving tion. LAAM is not yet routinely used in the treat- may continue as well as increased susceptibility to ment of opioid dependence, and additional studies relapse in response to environmental cues. will be necessary to determine the appropriate use Pharmacotherapy for cocaine dependence may of this agent. be used to alleviate symptoms experienced during Buprenorphine. Buprenorphine is a mixed the cocaine abstinence syndrome. During the crash opioid agonist/antagonist that has been used for period, early symptoms such as anxiety and insom- several years as a possible maintenance medication nia may be relieved by benzodiazepines such as for opioid dependence. Although it has only re- CHLORDIAZEPOXIDE. Neuroleptics (ANTIPSYCHO- cently been available within the United States, pre- TICS) may also be helpful during this period to liminary studies indicate that it may be a promising alleviate psychotic symptoms such as paranoia. agent for the treatment of opioid dependence. As Other agents that may be used on a short-term with methadone, maintenance treatment consists basis include dopaminergic agents such as bro- of daily administration of buprenorphine, but the mocriptine and AMANTADINE. Some investigators optimal daily dose of medication remains under postulate that CNS dopamine may be depleted by investigation. At low doses, buprenorphine has ag- chronic cocaine use. Dopaminergic agents may be onist effects at opioid receptors, but at higher doses used to augment CNS dopaminergic function, and antagonistic effects may occur. Buprenorphine various dopaminergic agents such as amantadine, maintenance has been associated with good treat- bromocriptine, and L-dopa have been employed ment retention, decreased illicit opiate use, and a for this purpose. Although few long-term, double- relatively mild withdrawal syndrome. On the basis blind, placebo-controlled studies have been con- of early studies, buprenorphine was thought to be a ducted, several studies have supported the use of promising agent in the treatment of both cocaine dopaminergic agents such as amantadine as an- and opioid dependence, but significant benefits ticraving medications during withdrawal. have not been confirmed by better-controlled Antidepressants may be helpful during the with- studies. drawal and extinction stages of cocaine abstinence. One controlled and several uncontrolled studies in recovering cocaine addicts suggested that the tri- COCAINE DEPENDENCE cyclic antidepressant desipramine might decrease Cocaine abuse has increased markedly since the cocaine use and craving. Other antidepressants in- 1970s, and by 1984, more than 20 million Ameri- vestigated in pilot studies include fluoxetine, imip- cans reported that they had tried cocaine. In addi- ramine, doxepin, and trazodone. Antidepressants tion to psychotherapy and other traditional ap- may take several weeks to begin to alleviate symp- TREATMENT TYPES: Pharmacotherapy, An Overview 1255 toms of depression or craving, however, and some able in the early 1990s. Detoxification from nic- cocaine addicts may drop out of treatment during otine may also be facilitated with the medication this period. These patients may benefit from initia- clonidine, the same agent used to help alleviate tion of treatment with a short-term agent (such as a opiate withdrawal symptoms. dopaminergic agent) followed by long-term treatment with an antidepressant. As with every treat- SEDATIVE DEPENDENCE ment, however, no firm conclusions are warranted about any agent until it has been tested in a con- Current treatments for sedative dependence in- trolled clinical trial that has been replicated at least clude detoxification agents rather than anticraving once. agents. Detoxification is accomplished by tapering Pharmacotherapy may also be helpful for pa- the dosage of benzodiazepines over two to three tients with psychiatric diagnoses other than cocaine weeks. More recently, carbamazepine, an an- dependence. In some patients, cocaine abuse may tiseizure medication, was shown to relieve alcohol be an attempt at self-medication to address the and sedative withdrawal symptoms, including sei- discomfort of depression or other psychiatric disor- zures and delirium tremens. Future work with ders. Patients with major depressive disorder and agents that block the actions of benzodiazepines bipolar disorder may respond to therapy with anti- may hold promise as a maintenance or anticraving depressants or lithium, and those with attention agent used to help the sedative abuser abstain from deficit disorder may benefit from the cautious use drug abuse. of low doses of stimulant medication. In summary, antipsychotics and benzodiaze- CONCLUSIONS pines may be used to alleviate symptoms of acute cocaine withdrawal, whereas tricyclic antidepres- Medications must be accompanied by psycho- sants and dopaminergic agents may be helpful in logical and social treatments and support; they do the long-term treatment of cocaine withdrawal. not work on their own. Moreover, medications to Pharmacotherapy should be considered an adjunct block illicit-drug effects in the brain may be of little to other forms of rehabilitative therapy during the use if the patient does not take them. More research long-term treatment of the cocaine-dependent in many fields is needed to identify potential medi- patient. cations, but this research must recognize the psychosocial as well as the neurobiological areas of therapy. Without this integration, the work to de- TOBACCO DEPENDENCE velop more effective treatments for the difficult One commonly used pharmacological treatment problem of drug abuse and dependence cannot for tobacco dependence is a nicotine-containing begin. gum called Nicorette. The main reason to quit smoking cigarettes is its powerful association with (SEE ALSO: Causes of Substance Abuse; Complica- lung cancer, emphysema, and other medical prob- tions; Disease Concept of Alcoholism and Drug lems. Yet nicotine, the active ingredient in ciga- Abuse; Nicotine Delivery Systems for Smoking Ces- rettes, is another drug that is associated with pleas- sation) ant effects and with withdrawal discomfort, thereby making it an extremely addicting drug. BIBLIOGRAPHY Providing cigarette smokers with nicotine replacement in the form of a gum will help them avoid the FRANCES, R. J., & FRANKLIN, J. E. (1990). Alcohol and health risks associated with smoking cigarettes. other psychoactive substance use disorders. In J. A. One problem with Nicorette is that it is difficult to Talbott, R. E. Hales & S. C. Yudofsky (Eds.), The chew correctly and therefore people need to be American Psychiatric Press textbook of psychiatry. trained in how to chew it in order to derive the Washington, DC: American Psychiatric Press. therapeutic effect. Recently, a patch has been de- GAWIN, F. H., & KLEBER, H. D. (1986). Abstinence veloped that is placed on the arm and automati- symptomatology and psychiatric diagnosis in chronic cally releases nicotine. A method that shows good cocaine abusers. Archives of General Psychiatry, 43, potential as a treatment, the patch was made avail- 107–113. 1256 TREATMENT TYPES: Psychological Approaches

JAFFE, J. H. (1989). Drug dependence: Opioids, nonuse is the balance between the rewards and the narcotics, nicotine (tobacco) and caffeine. In H. I. punishments of use. CONTINGENCY MANAGEMENT,a Kaplan & B. J. Sadock (Eds.), Comprehensive text- system of rewards for abstinence and punishment book of psychiatry (5th ed.). Baltimore: Williams & for drug use, is an example of an operant-based Wilkins. treatment. JAFFE, J. H. (1985). Drug addiction and drug abuse. In Classical Conditioning. A second model used A. G. Gilman et al. (Eds.), Goodman and Gilman’s is classical conditioning. A neutral event is paired the pharmacological basis of therapeutics, 7th ed. repeatedly with another important event, one that New York: Macmillan. usually evokes a response for the organism. A man KOSTEN, T. R., & KLEBER,H.D.(EDS.). (1992). Clini- who has experienced heroin withdrawal many cian’s guide to cocaine addiction. New York: Guilford times may eventually find that certain rooms of his Press. apartment itself have come to cause him to crave LOWINSON, J. H., RUIZ, P., & MILLMAN,R.B.(EDS.). drugs, because the apartment itself has become (1992). Baltimore, MD: Williams & Wilkins. associated with withdrawal. A treatment based on SCHUCKIT, M. A., & SEGAL, D. S. (1987). Opioid drug classical conditioning, for example, is an attempt to use. In E. Braunwald et al. (Eds.). Harrison’s princi- remove the craving induced by the sight of drug ples of internal medicine, 11th ed. New York: paraphernalia, by repeatedly presenting pictures of McGraw-Hill. those paraphernalia with no drugs, and therefore ELIZABETH WALLACE with lack of a reinforcing response. THOMAS R. KOSTEN Social Learning Models. Other treatments draw from social learning models. These assume that behaviors, such as drug abuse, are learned in Psychological Approaches Psychological many ways, including operant conditioning, classi- treatments of drug dependence assume that drug cal conditioning, imitation (learning by watching abuse is a learned behavior. As such, it is not differ- someone else), and learning certain ways of think- ent from other less controversial and more health- ing. These models also usually assume that imita- ful behaviors in its development. That is, a psycho- tion and learning new ways of thinking are more logical perspective suggests that drug abuse is, for important for humans than other ways of learning. the most part, learned in many of the same ways as An example of a treatment based on a social learn- behaviors such as reading or driving a car. This ing model is cognitive behavioral psychotherapy, perspective also suggests that drug abuse can be where the drug abuser is taught new ways of view- changed in the ways that other behaviors are ing old situations, as well as new social skills, in the changed. Forces for change include rewards (rein- hope that these new thoughts and skills will lead to forcers) and unpleasant events (punishments); cues a less troubled life, which does not demand drug that signal the need for specific actions (discrimina- abuse to make it tolerable. tive stimuli); and training in new ways of thinking about oneself and the world that lead to ways of OPERANT MODELS: living that do not involve drugs. CONTINGENCY MANAGEMENT Operant Learning Models. Psychological treatments for drug abuse can be grouped into Contingency management has been incorpo- three categories, based on the models of behavior rated into many drug-treatment programs as a way that they represent. The first are those that draw of assisting people in reducing drug use. In contin- from operant learning models. These models sug- gency management, reinforcers or punishers are gest that many important behaviors, including applied depending on the patient’s behavior. Often, those many behaviors that end with the use of an contingencies are formalized in a contract. In con- illegal drug are controlled by environmental events, tingency contracting, a treatment plan is developed rather than events inside the individual. Internal and agreed to by treatment staff and patient. As events may come into play but, ultimately, these part of the contract, both agree that certain conse- are caused by external events. These models sug- quences will occur as a result of certain behaviors gest that the important factor in determining drug on the part of the patient. TREATMENT TYPES: Psychological Approaches 1257

Early work indicating the usefulness of contin- CLASSICAL CONDITIONING: gencies was completed largely at Johns Hopkins AVERSIVE CONDITIONING University. Working in a methadone-maintenance A form of behavioral therapy once widely used is program, investigators at Johns Hopkins found that AVERSION THERAPY. Here, the drug or the cues that money and the opportunity to raise dose levels all remind drug users of it are paired with unpleasant served to decrease drug abuse. Work at the Univer- events. The notion is that by pairing this very desir- sity of California in detoxification treatment pro- able substance with an unpleasant event, the asso- grams also indicated that payment for drug absti- ciation with the substance will become negative. nence was an effective adjunct to short-term The most successful of these has been rapid smok- detoxification treatments, where methadone is used ing, a treatment for tobacco dependence. In rapid for only about three weeks, to help drug abusers in smoking, the smoker smokes and inhales at a rate their transition from heroin use to a drug-free state. about 6 times that of normal. During this process, Both of these experimental programs focused on the therapist points out negative things about rewards for desired behavior, rather than punish- smoking, including the smell of the smoke, burning ments for drug use. Contingencies also have been eyes, racing heart, and pounding head. Over time, used to help clients conform to other treatment de- the poisonous elements of the smoke itself (usually mands, including attending counseling sessions an amount of NICOTINE that exceeds the smoker’s (Stitzer & Kirby, 1991). tolerance) may make the smoker nauseated. Thus, Even though early work focused on providing the cues associated with a cigarette (its appearance positive reinforcers for desired behavior, the adap- and smell) rather than calling forth pleasant reac- tations of this work in most clinics around the tions in the smoker, come to call forth unpleasant country has involved negative consequences. For ones. Aversive-conditioning treatments have been reasons not clear, most clinical sites that have attempted with other drugs, most notably ALCO- adopted the contingency contracting procedures HOL and COCAINE. Usually, for example, a chemical use punishers, not reinforcers. A common example that induces vomiting is given so that nausea and is the use of a detoxification contract in methadone- vomiting occur at about the same time the patient is maintenance treatment. Frequently, patients who drinking in a controlled setting. However, aversion are using illegal drugs sign a contract with treat- treatments for drug abuse other than TOBACCO ment staff indicating that if they do not terminate abuse have had limited success or, at least, limited all unapproved drug use within a certain period of popularity. There are at least two reasons for this. time, their methadone dose will be reduced. If they First, with other drugs, the dose of the problem drug needed to produce unpleasant reactions may continue to use drugs, their dose is incrementally be physiologically dangerous. Second, rapid smok- reduced until they are no longer receiving metha- ing is unique in that it is the actual drug, tobacco done. At any point in the sequence, however, that smoke, that is used to form the aversion. There is the patient shows evidence of discontinuing drug evidence in the psychological literature that such use, the methadone dose can be raised and the aversions are especially potent. person continued on the treatment program. Usu- Aversive smoking has been evaluated in several ally, the contract indicates that patients are given a well-controlled studies. It appears that when it is certain amount of time to decrease the number of done correctly, abstinence rates can be as high as drug-positive urines or they are gradually detox- 60 percent after one year—a very high abstinence ified from the program. rate indeed—since the average abstinence rate af- Contingency management has been used with ter treatment for cigarette smoking is about 20 practically every addiction, both by itself and in percent. The data for aversion for alcoholics using conjunction with other treatments. The evidence is chemicals is not so clear. There are few compari- now convincing that contingencies, especially posi- sons with other treatments or with no treatment. tive contingencies, are effective in decreasing drug Individuals who choose aversion treatment may be abuse. Work is needed to train clinic staff in using especially motivated to change, and they might contingency programs, especially those employing have achieved high abstinence rates even without positive contingencies (Stitzer & Kirby, 1991). treatment. 1258 TREATMENT TYPES: Psychological Approaches

One variant of aversion conditioning is covert they would role-play the alternative responses. The conditioning. In covert conditioning, the drug therapist would play the role of both the boss and abuser, with the help of a therapist, imagines both the smoker, to give the smoker a model of different the drug use and the unpleasant consequences of it. ways to handle the situation. In this way, the For example, alcoholics might picture a cold beer, smokers would learn to handle anger in a better prepare to savor it, took at it, sip it, then slowly feel way, would be satisfied with the new responses, and increasingly nauseated until they become violently be less likely to smoke. The smoker would also have ill. Thus, both the aversive events and the unpleas- ready responses other than smoking. Skill-training ant consequences are imagined, rather than real. programs have been studied with smokers, alcohol- This has advantages if the drug of choice is illegal ics, cocaine abusers, and abusers of multiple drugs. or quite dangerous, because it avoids drug use at Skill training is closely related to the recovery all. Also, patients who might refuse to participate in training and self-help that is discussed below. Re- actual aversive conditioning may feel able to do so cent data indicate skill training may be an espe- when the aversion experienced is imagined. Unfor- cially useful treatment for heroin and/or cocaine tunately, however, there is not a great deal of evi- abusers and alcoholics when used in the context of dence to support the usefulness of this approach a large therapy program (Carroll, Rounsaville, & (Council on Scientific Affairs, 1987). Gawin, 1991). The use of aversion conditioning has decreased Skill training has been shown to be especially recently, except in a limited number of private psy- useful as an ancillary to other treatments. For ex- chiatric hospitals. There are several reasons con- ample, one program developed a workshop to train tributing to its demise. The first is the lack of drug-treatment patients in job-finding skills. There demonstrated efficacy in controlled clinical trials was a great deal of practice in new ways to inter- with drugs other than tobacco. The second is its view for jobs. Patients were taught how to fill out a expense when compared with other treatments. job application to maximize their strengths—also Last, because of its intrinsically unpleasant nature, how to handle the existence of prison records or it has low acceptability. long lapses in employment. They practiced their interviews and saw themselves in practice inter- SOCIAL LEARNINGMODELS views on videotape. The rationale was that if drug abusers could be taught to present themselves posi- Skill Training. In skill training, drug abusers, tively in a job interview, they would be more likely and others at risk for drug abuse, are taught skills to get jobs. And, were they to become employed, that will help them not to use drugs. These can be they would be less likely to use drugs, for several simple and direct; for example, teaching junior reasons. These reasons include increased general high school students effective ways to refuse a ciga- life satisfaction and making new friends and social rette. The skills learned may also be complex. Con- contacts who are not drug abusers. Studies using sider, for example, a smoker who knows the temp- this technique found that it was helpful in increas- tation to smoke when angry, because in the past ing employment rates in both METHADONE- anger-provoking situations have resulted in re- MAINTENANCE clients and former addicts recruited lapse. A therapist working with such a person in from the criminal-justice system. These studies did skill training would first review the situations that not address the length of time the job was held, produce anger. These might be as diverse as incor- however. It may be that a separate set of skills is rect charges on a credit card bill to a fight with the needed to maintain employment. This set should be boss. After identifying the situations, the smoker the object of further study (Hall et al., 1981). and therapist would then discuss the details of the Some programs have attempted to combine sev- situation. For example, they might imagine what eral approaches, so that abstinence is supported in the boss would say to smokers to elicit anger. They multiple ways. Among the most successful of these would attempt to find ways of handling the situa- is the community-reinforcement approach to alco- tion that would leave the smokers feeling satisfied holism treatment developed by Azrin (1976). The after it was over. They would discuss the usual original community-reinforcement approach in- response that would culminate in smoking. They corporated (1) placement in jobs that interfered would then identify alternative responses. Finally, with drinking; (2) marriage and family counseling; TREATMENT TYPES: Psychological Approaches 1259

(3) a self-governing social club; and able included one focusing on feelings and emo- (4) encouragement to engage in hobbies and recre- tions (supportive—expressive) and one focusing on ational activities that could substitute for drinking. thought and behaviors (cognitive—behavioral). This procedure was found to decrease time spent These researchers found that the type of therapy drinking alcohol, increase rates of employment, in- was not important, just participating in therapy crease time spent with families, and decrease the was important (Woody et al., 1983). time spent in the hospital being treated for alcohol- The Recovery Training and Self-Help ism. A later revision of the program also encour- Model. Researchers at Harvard University stud- aged patients to take DISULFIRAM, a drug which ied a model that combined skill training in Relapse produces unpleasant reactions if one drinks after Prevention with Self-Help Groups. In their study, taking it; taught alcoholics how to identify and opiate addicts attended a recovery-training session handle danger signals so that they did not lead to once a week and a self-help group led by a former drinking; provided patients with a ‘‘buddy’’ in the addict. Members also met informally outside the client’s neighborhood; and switched from individ- treatment meetings and in group-sponsored recre- ual to group counseling. This procedure produced ation and community activities. In the profession- even more strikingly positive results than the origi- ally led recovery meetings, leaders addressed a nal program. It can be argued that subjects in these variety of topics, including high-risk situations, studies had resources available to them that many friendships, physical illness, and relations with drug abusers and alcoholics do not have, including family; they developed new ways of handling these the opportunity to receive inpatient treatment, a situations that would be less likely to lead to drug local economy that provides a choice of job oppor- use. The self-help groups supported these changes tunities, and supportive families. Recent work with and further reinforced them. In two studies, one in cocaine abusers has replicated these positive re- the United States and one in Hong Kong, this treat- sults. The finding is especially impressive because ment led to higher rates of abstinence or infrequent the cocaine abusers were treated on an outpatient use than was found in a control condition, to in- basis, and they traditionally have fewer resources creases in employment, and to fewer reports of than alcoholics. criminal behavior. These differences were quite Psychotherapy. Psychotherapy has also been long-lasting—occurring six months to one year af- useful in treating drug addicts, especially those ter entrance into treatment (McAuliffe & Ch’ien, with social and psychological problems that com- 1986). plicate their drug abuse. The assumption behind Twelve-Step Programs. The most well- providing psychotherapy to drug abusers is that known TWELVE-STEP program for helping sub- drug abuse is motivated by the problems that abus- stance abusers is ALCOHOLICS ANONYMOUS (AA). ers have with other people, as well as their feelings AA, founded in 1935 by a group of recovering alco- about themselves. Early workers in the field at- holics, is a fellowship of men and women who are tempted to provide psychotherapy as the sole treat- committed to helping other alcoholics. NARCOTICS ment for drug abuse. Most found that it was not ANONYMOUS (NA), founded in 1953, was adapted successful; they assumed that this was because the from AA principles to include all substance abus- personality characteristics of addicts were not those ers, not only alcoholics. that allowed people to succeed in psychotherapy— AA and NA programs focus on alcoholism and that is, addicts are often distrustful of nonaddicts substance abuse as a disease for which there is no and may not easily reveal their feelings to profes- cure—therefore recovery becomes a lifetime com- sionals. Also, they may not be especially reliable mitment. These programs emphasize the personal and often appear to have shaky to no motivation to powerlessness of individuals in combating their ill- change. Nevertheless, a large-scale study at the ness and get individuals to recognize that they must University of Pennsylvania—using clients who give themselves to a greater power so that they may were already in methadone maintenance—found be saved. that, in the context of a larger treatment program, The guiding tenets of AA and NA programs are drug-treatment clients with other or extensive psy- called the Twelve Steps. Each step is a passage chological problems do benefit from the addition of through recovery, combining self-discovery with psychotherapy. The forms of psychotherapy avail- spiritual guidance. They involve five psychological 1260 TREATMENT TYPES: Self-Help and Anonymous Groups

tasks: (1) recognition and admission of powerless- BIBLIOGRAPHY ness over alcohol; (2) acceptance of a high power as ANDERSON,J.G.,&GILBERT, F. S. (1989). Communica- a source of strength and guidance during recovery; tion skills training with alcoholics for improving per- (3) self-help appraisal and self-disclosure in the formance of two of the Alcoholics Anonymous recov- service of personal change; (4) making amends for ery steps. Journal of Studies on Alcohol, 50, 361–367. past wrongs; and (5) carrying the AA message to AZRIN, N. H. (1976). Improvements in the community- others (Anderson & Gilbert, 1989). reinforcement approach to alcoholism. Behavior One can argue that aspects of AA parallel psy- Besearch and Therapy, 14, 339–348. chological approaches. For example, similar to psy- CARROLL, K. M., ROUNSAVILLE, B. J., & GAWIN,F.H. chotherapy, AA and NA members are encouraged (1991). A comparative trial of psychotherapies for to ‘‘work through’’ problems and to change the ambulatory cocaine abusers: relapse prevention and attitudes and actions associated with an alcohol- or interpersonal psychotherapy. American Journal of drug-using lifestyle. These programs also use prin- Drug and Alcohol Abuse, 17(3), 229–247. ciples common to other self-help groups. Members COUNCIL ON SCIENTIFIC AFFAIRS. (1987). Aversion ther- are encouraged to attend meetings on a daily or apy. Journal of the American Medical Association, weekly basis, at which the steps are discussed and 258, 2562–2566. made relevant, speakers recount their lives, and EMRICK, C. D. (1987). Alcoholics Anonymous: Affiliation connections with support networks and role models processes and effectiveness as treatment. Alcoholism, are made. 11, 416–423. Nevertheless, despite the facility with which psy- HALL, S. M., ET AL. (1981). Increasing employment in chological models might explain such approaches, ex-heroin addicts II: Criminal justice sample. Behav- they are not psychological approaches. They were ior Therapy, 12, 453–460. developed from a spiritual approach, not from psy- MCAULIFFE, W. E., & CH’IEN, J. M. (1986). Recovery chological principles. training and self-help. Journal of Substance Abuse Treatment, 3, 9–20. SUMMARY OGBORNE, A. C., & GLASER, F. B. (1981). Characteristics There are many psychological treatments that of affiliates of Alcoholics Anonymous: A review of the appear to be useful in aiding drug abusers to stop literature. Journal of Studies on Alcohol, 42, 661– using drugs, no matter whether the drug be an 675. illegal one, or alcohol or nicotine. Positive results SHEEREN, M. (1988). The relationship between relapse come from contingency-contracting programs and and involvement in Alcoholics Anonymous. Journal of Studies on Alcohol, 49, 104–106. multifaceted-reinforcement programs that are of- STITZER, M. L., & KIRBY, K. C. (1991). Reducing illicit fered in the context of complex treatment programs drug use among methadone patients. In Improving or from skill-training programs that address sev- Drug Abuse Treatment (National Institute on Drug eral facets of the drug abuser’s life. Also, there is Abuse Research Monograph 106). Rockville, MD: Na- evidence for the usefulness of different forms of tional Institute on Drug Abuse. psychotherapy for drug abusers, especially for WOODY, G. E., ET AL. (1983). Psychotherapy for opiate those who have psychological and social problems. addicts. Archives of General Psychiatry, 40, 639– Drug abuse is increasingly becoming identified as a 645. complicated problem that involves both biological and psychological factors. Because of this and the SHARON HALL clear usefulness of psychological intervention, we MERYLE WEINSTEIN can expect to see the development of new psychological treatments for drug abuse. Self-Help and Anonymous Groups Self- (SEE ALSO: Addiction: Concepts and Definitions; help groups for drug and alcohol abuse, often Adjunctive Drug Taking; Causes of Substance called mutual-help groups, are of two basic types. Abuse; Disease Concept of Alcoholism and Drug First are the long-standing anonymous groups Abuse; Prevention; Vulnerability; Wikler’s Pharma- closely patterned after ALCOHOLICS ANONYMOUS cologic Theory of Drug Addiction) (AA). An alternative type also has a group context, TREATMENT TYPES: Self-Help and Anonymous Groups 1261 but rejects the spiritual aspects (such as reliance on 9. Made direct amends to such people wherever ‘‘higher power’’) of AA and urges members instead possible, except when to do so would injure to take personal responsibility for gaining sobriety. them or others. The AA-like anonymous groups embrace the 10. Continued to take personal inventory, and TWELVE STEPS, applying them to their own partic- when we were wrong, promptly admitted it. ular disorder. In some instances, they also adapt 11. Sought through prayer and meditation to im- the AA Twelve Traditions. NARCOTICS ANONYMOUS, prove our conscious contact with God as we Emotions Anonymous, Overeaters Anonymous, understood Him, praying only for knowledge Gamblers Anonymous, AL-ANON,COCAINE ANONY- of His will for us and the power to carry that MOUS, and Nicotine Anonymous are prominent ex- out. amples. Examples of the alternatives to AA are RA- 12. Having had a spiritual awakening as the result TIONAL RECOVERY (RR), SECULAR ORGANIZATION of these steps, we tried to carry this message to FOR SOBRIETY (SOS), and WOMEN FOR SOBRIETY others, and to practice these principles in all (WFS). Numerous members of these groups have our affairs. been dropouts from AA. SOURCE: The Twelve Steps are reprinted with In embracing AA’s Twelve Steps, the first type of permission of Alcoholics Anonymous Word Ser- organization teaches powerlessness over their mal- vices, Inc. Permission to reprint this material does ady, reliance on the group or on some entity as a not mean that AA has reviewed or approved the ‘‘higher power,’’ catharsis via self-inventory, con- contents of this publication, nor that AA agrees fession and amends, and a commitment to search with the views expressed herein. AA is a program of out and tell others suffering from the same disorder recovery from alcoholism only—use of the Twelve about their programs for recovery. The rationale is Steps in connection with programs and activities that members have deep-seated denials that must patterned after AA, but which address other prob- be blunted by admitting helplessness and invoking lems, does not imply otherwise. the group and a higher power to help them. More- over, this powerlessness is seen as a lifetime condi- The second type of organization emphasizes that tion and the Twelve Steps are seen as providing a individuals, as individuals, must use their own re- mechanism for ensuring a lifetime cessation of the sources and, in effect, ‘‘Save Our Selves’’ (SOS). compulsive behavior. The steps were devised in the The founder of WFS has written Thirteen State- late 1930s by Bill W., the major cofounder of AA, in ments of Acceptance around which meetings are conjunction with a small group of his earlier anchored: For example, number 5 is ‘‘I am what I followers. think,’’ and number 13 is ‘‘I am responsible for The Twelve Steps of Alcoholics Anonymous. myself and my actions.’’ The other statements encourage in women alcoholics a strong feeling of 1. We admitted we were powerless over alcohol— self-worth even though they have symptoms of a that our lives had become unmanageable. serious disease (Kirkpatrick, 1989). 2. Came to believe that a Power greater than The two types of organizations differ on basic ourselves could restore us to sanity. treatment strategies. One difference is their diver- 3. Made a decision to turn our will and our lives gent views of the permanency of their obsessive over to the care of God as we understood Him. behavior. AA, and the many AA-like groups, view 4. Made a searching and fearless moral inventory their problems as lifetime conditions over which of ourselves. they are powerless. In short, they will never re- 5. Admitted to God, to ourselves, and to another cover; they are permanently ‘‘recovering’’ from a human being the exact nature of our wrongs. disease. In contrast, RR, for example, plays down 6. Were entirely ready to have God remove all the disease concept, and the higher-power notion these defects of character. that goes with it, and appeals to forces within a 7. Humbly asked Him to remove our shortcom- member’s own intellect and willpower. Self-reli- ings. ance is taught. WFS targets the development of 8. Made a list of all persons we had harmed, and self-value, self-esteem, and self-confidence as a became willing to make amends to them all. way to meet the emotional needs of modern 1262 TREATMENT TYPES: Therapeutic Communities

women, thereby, members believe, reducing signif- EMRICK, C. (1089). Alcoholics Anonymous: Membership icantly the basic roots of alcohol abuse for them. characteristics and effectiveness as treatment. In M. The success rates of the AA fellowship have been Galanter (Ed.), Recent developments in alcoholism: assessed at two points in time. Of those initially Treatment and research (pp. 37–53). New York: Ple- attracted to AA, a large proportion drop out— num Press. somewhere between 35 and 65 percent. Of those EMRICK, C. D., LASSEN,C.L.&EDWARDS, M. T. (1977). who become active members, 65 to 70 percent Nonprofessional peers as therapeutic agents. In A. S. ‘‘improve to some extent, drinking less or not at all German & A. M. Razin (Eds.), Effective psychother- during A.A. participation’’ (Emrick, 1989:45). apy: A handbook of research (pp. 120–161). New Membership in AA seems to be associated with York: Pergamon Press. relatively high abstinence rates, but with fairly typ- HALL, T. (1990). New way to treat alcoholism shuns ical improvement rates (Emrick, Lassen, & Ed- spirituality. New York Times, December, 4, 1, 46. wards, 1977). It appears that AA is effective only KIRKPATRICK, J. (1990). Women for sobriety. The Coun- with some 25 to 30 percent of the population with selor, January/February: 9. alcohol-related problems. AA, then, is a highly se- OGBORNE, A. C., & GLASER, F. B. (1981). Characteristics lective treatment source—attracting and holding of affiliates of Alcoholics Anonymous: A review of the those alcohol-troubled persons with severe alcohol literature. Journal of Studies on Alcohol, 42(7), 661– problems who have high affiliative needs, conform- 675. ist tendencies, proneness to guilt, and need for ex- T RICE,H.M.,&ROMAN,P.M.(1970).So- ternal controls (Trice & Roman, 1970; Ogborne & ciopsychological predictors of affiliation with Alcohol- Glaser, 1981). ics Anonymous: A longitudinal study of ‘‘treatment Unfortunately, the alternative type of organiza- success.’’ Social Psychiatry, 5, 51–59. tion has yet to be scrutinized by objective research- HARRISON M. TRICE ers. But subjective estimates of the number of groups and members have been put forward. SOS claims 1,000 groups with 2,000 members (Christo- Therapeutic Communities Therapeutic pher, 1992); Hall (1990:1,46) has estimated that communities (TCs) are drug-free residential treat- RR has meetings in 100 cities, ‘‘with perhaps two ment facilities for drug and/or alcohol addiction. thousand members at any one time,’’ and Hall TCs emerged in the 1960s as a self-help alternative (1990) estimated 5,000 members in 32 groups for to the conventional medical and psychiatric ap- WFS. Assuming that, like AA, there are dropouts proaches being used at that time. and misfits for each type of group, these numbers Most traditional TCs have similar features, in- must be sharply discounted. Nevertheless all three cluding their organizational structure, staffing pat- have demonstrated some staying power. SOS even terns, perspectives, rehabilitative regimes, and a publicizes itself as a demonstrated and proven al- twelve- to eighteen-month duration of stay. They ternative to AA. As yet no reliable data support this differ greatly, however, in size (30-600 beds) and contention, but the fact that sizable numbers have client demography. Most people entering TCs have been attracted to it suggests that it, or groups like used multiple drugs-including TOBACCO,MARI- it, are realistic contenders for some of AA’s approx- JUANA,ALCOHOL,OPIODS, pills, and, recently, CO- imately 1 million members. CAINE and CRACK-cocaine. In addition to their substance abuse, most TC clients also have a (SEE ALSO: Alcoholism; Disease Concept of Alcohol- considerable degree of psychosocial dysfunction ism and Drug Addiction; Ethnic Issues and Cultural (Jainchill, 1994). In traditional TCs, 70 to 75 per- Relevance in Treatment; Women and Substance cent of clients are men, but admission for women is Abuse) increasing. Most community-based TCs are integrated across gender, race/ethnicity, and age. Pri- mary clinical staff are usually former substance BIBLIOGRAPHY abusers who were rehabilitated and trained. Other CHRISTOPHER, J. (1992). The S.O.S. story. S.O.S. Na- staff are the professionals who provide medical, tional Newsletter, 5(1), 1, 2. mental health, vocational, educational, family- TREATMENT TYPES: Therapeutic Communities 1263

meetings, and general meetings facilitate assimila- tion into the community as a context for social learning. Clients are oriented into the program during the orientation-induction stage. They progress through the primary treatment stage of the program by achieving plateaus of stable behavioral change. Client development reflects their changing relationship with the community, characterized as compliance, conformity, and commitment. Finally, reentry represents the final program stage where the skills needed in the greater social environment are fostered through increased self-management More than 500 women from Synanon and decision making. communities throughout California shaved their The effectiveness of the traditional long-term heads to symbolize acceptance of equal residential TC, as described here, has been well- responsibility—with Synanon men—for the documented (De Leon, 1997, 2000). Today, TCs management and operation of the therapeutic include a wide range of programs serving diverse communities. Oakland, February 27, 1975. clients who use a variety of drugs and present (᭧ Bettmann/CORBIS) complex social/psychological problems. Client differences, clinical requirements, and funding realities have all encouraged the development of counseling, fiscal, administrative, and legal ser- modified residential TCs with shorter stays (3, 6 and 12 months) as well as TC-oriented day treat- vices. ment and outpatient models. Most traditional TCs Traditional TCs share a defining view of sub- have expanded their social services or incorporated stance abuse as a deviant behavior, which may be new interventions to address the needs of special attributed to psychological factors, poor family ef- populations such as adolescents, mothers and chil- fectiveness, and, frequently, to socioeconomic dis- dren, homeless, mentally ill chemical abusers, and advantage. Drug abuse is thus seen as a disorder of prison inmates. In these modifications the cross- the whole person and recovery as a change in life- fertilization of personnel and methods from the style and personal identity. As part of the recovery traditional TC, mental health, and human services process, TCs seek to eliminate antisocial attitudes portends the evolution of a new therapeutic com- and activity, develop employable skills, and munity. inculcate prosocial attitudes and values. This TC view of recovery is based upon several broad as- BIBLIOGRAPHY sumptions: the client’s motivation to change, the client’s main contribution to the change process DE LEON, G. (2000). The therapeutic community: The- (self-help), the mediation of this recovery through ory, model, and method. New York: Springer Publish- peer confrontation and sharing in groups (mutual ing Company. self-help), the affirmation of socially responsible DE DEON, G. (Ed.). (1997). Community as method: roles through a positive social network, and the Therapeutic communities for special populations and understanding that treatment is a necessarily in- special settings. Westport, CT: Greenwood Publishing tense ‘‘episode’’ in a drug user’s life. Group, Inc. Diverse elements and activities within the TC JAINCHILL, N. (1994). Co-morbidity and therapeutic foster rehabilitative change. Junior, intermediate, community treatment. In F. M. Tims, G. De Leon, & and senior peer levels stratify the community, or the N. Jainchill (Eds.), Therapeutic community: Ad- family. The TC’s basic program elements, consist- vances in research and application. National Institute ing of individual counseling and various group pro- on Drug Abuse Research Monograph 144. Publication cesses, make up the therapeutic and educative ele- no. 94-3633 (pp. 209–231). Rockville, MD: National ments of the change process. The daily activities, Institute on Drug Abuse. including morning meetings, seminars, house GEORGE DE LEON 1264 TREATMENT TYPES: Traditional Dynamic Psychotherapy

Traditional Dynamic Psychotherapy mation provided by the patient. Important issues to Dynamic psychotherapy is the term for the various be explored in treatment include current relation- psychological treatments, primarily talking treat- ships (with spouse, children, friends, coworkers), ments, intended to modify and ameliorate behav- past relationships (with parents and other family), iors based on inner conflicts (e.g., ‘‘Should I study and the relationship within the treatment between for the test or cheat?’’) and/or interpersonal con- the patient and the therapist. Often, the difficulties flicts (difficulties with others). These techniques and distortions within this relationship mirror past range from those intended primarily to support in- and current relationships and may be used to help dividuals, lending them the therapist’s strength or the patient see the nature and impact of the past on understanding (‘‘If you do that you’ll get in trouble. current behaviors. Have you thought of handling it this way?’’), to Treating substance abusers can be frustrating helping patients reach their own understanding of for therapists; there are many slips with return to the origins and implications of their behaviors. The drug use, and patient behavior is often calculated application of these techniques to the treatment of to make the therapist angry and to give up. It is alcoholics and substance abusers is supported by essential that therapists who make the attempt the high incidence of cooccurrence of psychiatric carefully monitor their own feelings so that they do illness—in several studies, 70 percent—some of not interfere with the treatment itself. It is also which may play a role in initiating or maintaining important to remember that when properly done, the behavior. It has been suggested that for some treatment can make the difference between suffer- substance abusers, the use of illicit compounds is a ing with chronic problems and successful adapta- misguided attempt at self-medication. Often, psy- tion. This is particularly true when substance abuse chotherapy must be provided in conjunction with is accompanied by other psychiatric disease and/or other treatments—pharmacologic, such as DI- disability. SULFIRAM for alcoholics or METHADONE for HEROIN abusers; SELF-HELP groups, such as ALCOHOLICS (SEE ALSO: Causes of Substance Abuse: Psychologi- ANONYMOUS; or family or group psychotherapy. cal (Psychoanalytic) Perspective; Disease Concept Psychotherapy is based on the assumption that of Alcoholism and Drug Abuse; Epidemiology) the patient will think and talk about ideas and feelings rather than acting upon them. This may prove particularly difficult for substance abusers BIBLIOGRAPHY who often have little sense of what they feel, other AMERICAN PSYCHIATRIC ASSOCIATION. (1989). Treatments than generalized pain, and who are used to action of psychiatric disorders: A task force report of the and immediate gratification. Therefore, treatment, American Psychiatric Association. Washington, DC: particularly at the beginning, must take place Author. within a structure that both supports and helps WILLIAM A. FROSCH control impulsive behavior. Sometimes, treatment starts in a hospital or other residential setting; often, it is accompanied by regular drug testing. After the agreement to start therapy and setting goals, Twelve Steps, The The heart of the therapist and patient meet once to several times a ALCOHOLICS ANONYMOUS (AA) is a program called week. As trust is developed between patient and the Twelve Steps set forth by cofounder Bill W. and therapist, the therapist can expect less lying and his early followers. The Twelve Steps establish a less denial of difficulties; treatment can, if indi- suggested, unfolding process for becoming, and re- cated, begin to move from support toward expres- maining, sober. The process begins with an admission of feelings—toward identification of conflicts sion of powerlessness over alcohol, along with un- and the understanding of their origins. Initially the manageable lives, and builds momentum gradually therapist listens, struggling to understand the pa- into a commitment to carry the AA program via the tient’s inner experience and its meaning. The thera- Twelve Steps to active alcoholics. Newcomers are pist then attempts to help patients to understand not pressed to follow all the steps if they feel unwil- what they have presented, with appropriate ling or unable to do so. This suggested policy seems changes and qualifications based on further infor- to be followed. Thus, Madsen (1974) found that 41 TREATMENT TYPES: Twelve Steps, The 1265 of the 100 AA members he studied had gone that they are in charge of themselves, that they are through all the Twelve Steps. And Rudy (1986:10) autonomous and able to govern themselves’’ reports that ‘‘in Mideast City, A.A. members talk (Khantzian & Mack, 1989:74). AA teaches that about and emphasize steps 1, 2, 3, 4, and 12 more until alcoholics accept the first step they will con- than others.’’ This pragmatic view of the Twelve tinue to believe a fiction—that they are clever Steps can be heard in an AA saying—‘‘Take the enough and strong enough to control their drink- best and leave the rest.’’ The steps are: ing. In any event, by taking the first step, newcomers to AA dramatically change their conception of 1. We admitted we were powerless over alcohol— self from believing they can control their drinking that our lives had become unmanageable. to believing they cannot ever do so. 2. Came to believe that a Power greater than In step one, AA taps into the repentant role in ourselves could restore us to sanity. U.S. tradition. Redemptive religions emphasize 3. Made a decision to turn our will and our lives that one can correct a moral lapse, even one of long over to the care of God as we understood Him. duration, by public admission of guilt and repen- 4. Made a searching and fearless moral inventory tance. AA members can assume this repentant role, of ourselves. beginning with step one, and it becomes, along with 5. Admitted to God, to ourselves, and to another the other steps, a social vehicle whereby they can human being the exact nature of our wrongs. reenter the community (Trice & Roman, 1970). 6. Were entirely ready to have God remove all This role is strengthened by step two and step these defects of character. three, wherein alcoholics agree there is a power 7. Humbly asked Him to remove our shortcom- greater than themselves who will help and agree to ings. turn their destiny over to this higher power as they 8. Made a list of all persons we had harmed, and conceive of it. In essence, members believe that one became willing to make amends to them all. does not have to stand alone against alcohol abuse 9. Made direct amends to such people wherever and the strains of life; AA offers the group itself and possible, except when to do so would injure its collective notion of a higher power to help the them or others. powerless. 10. Continued to take personal inventory, and By accepting and executing step four and step when we were wrong, promptly admitted it. five, AA members believe they are engaging in a 11. Sought through prayer and meditation to im- realistic self-examination of the factors of fear, prove our conscious contact with God as we guilt, and resentment that cause their drinking. In understood Him, praying only for knowledge step four, new members list all people they now of His will for us and the power to carry that resent or have resented in the past. Along with this out. list, newcomers note what they believe to be the 12. Having had a spiritual awakening as the result substance of the resentment. Following this exer- of these steps, we tried to carry this message to cise, new members work out ways to try to alter alcoholics and to practice these principles in all conceptions of these resented persons. They also our affairs [Alcoholics Anonymous World Ser- attempt an inventory of their own behaviors that vices, 1976:59]. have contributed to their fears, guilts, and Step one meant for Bill W., the founder of AA, resentments. In step five, alcoholics acknowledge ‘‘the destruction of self centeredness’’ (Alcoholics these inventories to a higher power and confess Anonymous, 1939:16). In informal talk, AA mem- them to some other individual. for example, a bers often urge everyone ‘‘to leave their egos at the friend, pastor, therapist, or sponsor. Members be- door.’’ Trice (1957:45) found that affiliation with lieve that this moral inventory and its reduction in AA was initially encouraged among those newcom- resentments enable them to live through emotional ers who reported that they had no willpower experiences that in the past were managed by the models among their friends or relatives for quitting abuse of alcohol. alcohol abuse. Many observers have noted the Steps six and seven are reinforcements of the strong tendency among alcoholics toward an ‘‘exchanges produced by acting out steps four and five. aggerated belief in the ability to control their im- In step six, members indicate and reaffirm a readi- pulses, especially the impulse to use alcohol . . . ness to respond to help from a higher power. In step 1266 TREATMENT TYPES: Twelve Steps, The

holic) meeting that often results in a sponsor-sponsoree relationship between a newcomer and older (in AA ‘‘birthdays’’) members. The group wisdom of AA teaches that new members are more likely to join during a crisis. Consequently, twelfth-step workers do not press for an admission of alcoholism during initial contacts. Rather, they try to be nonjudgmental, accepting, and reassuring, while nevertheless trying to help the prospect define the problem and what he or she will do about it. Mem- bers do, however, briefly describe their recovery via AA and invite the prospect to come to their meet- The meeting room at the Wilson House in East ings. If there is a positive response, they will prom- Dorset, Vermont. The birthplace of Alcoholics ise to take the prospective member. According to Anonymous co-founder Bill Wilson serves as an Bales (1962:575), the sponsor-sponsoree relation- inn and a gathering place for AA participants. ship, along with the actual twelfth-step work itself, (AP Photo/Craig Line) is ‘‘the heart of the therapeutic process’’ in AA. The use of these steps is supported by basic seven, with as much humility as possible, members assumptions: that intense self-examination and actually request that the higher power help them confession are cathartic; that alcoholics cannot eliminate the inventory of ‘‘shortcomings’’ assem- control even moderate drinking and therefore are bled by the member. In steps eight and nine, mem- incapable of drinking at all. In other words, ‘‘once bers seek to make further changes and reinforce an alcoholic, always an alcoholic.’’ According to the past changes by providing restitution to those they first step, ‘‘We admitted we were powerless over have hurt in the past. Members list those actually alcohol.’’ The assumption of being powerless has harmed by their past behaviors and then do as been the focus of considerable controversy outside much as they can to make amends and try to cancel AA. The controversy centers around a follow-up out the harm caused. Most members agree that study of 11,000 alcoholics whose drinking patterns some amends might actually do harm to either were obtained 6 months and 18 months after expe- themselves or others and caution against them. For riencing one of a variety of treatment programs. example, the member might grievously damage a The study, which contained numerous flaws (e.g., spouse by confessing in detail sexual infidelities. short follow-up time), showed that the majority of Step ten is a repetition and a reinforcement of steps former alcoholics (who drank, on average, more four and five. In this step, members continue to than 8 ounces a day of ethanol [alcohol]) who had ‘‘take my moral inventory’’ and admit their wrongs experienced a treatment program could drink mod- to themselves, others, and the Greater Power. Step erately (2.5 ounces per day) at levels that many eleven also acts as an implementer, but this time for believe to be no problem (Armor, Polich, & step three, in which through meditation and prayer Stambul, 1976). they again decide to turn over their willpower and A competing assumption is that ALCOHOLISM is a their lives to a higher power. disease—that alcoholics suffer from an ‘‘allergy.’’ Step twelve is the culmination of all these steps. This belief has also been controversial. An alterna- Members are urged to carry their experiences and tive has been the concept of the ‘‘problem drinker,’’ stories to active alcoholics in treatment centers, the heavy drinker who gets into trouble, directly or hospitals, even homes—in effect, to offer the re- indirectly, because of drinking alcohol. This by- demptive model of AA sobriety to them. AA partici- passes the debate about alcoholism being a disease pants argue that, by becoming helpers, they help and about the amount drunk; it focuses instead on themselves at the same time and that they derive the ‘‘problem’’ correlates of drinking, that is, a new commitments to the truths believed to be role-impairment definition—financial problems manifest in the other eleven steps. Furthermore, in and problems with family, police, friends, and twelfth-step work, there is a one-on-one, often a neighbors. For example, Trice (1966:29) suggests two-on-one (two AA members and one active alco- that role impairment—such as job impairment— TRIPLICATE PRESCRIPTION 1267

would be one of the performance criteria for the C. R. Snyder (Eds.), Society, culture, and drinking definition of alcoholism: alcoholics differ from patterns, pp. 573–578. New York: Wiley. those around them because the performace of their KHANTZIAN, E. J., & MACK, J. E. (1989). Alcoholics adult roles becomes clearly impaired by their recur- Anonymous and contemporary psychodynamic the- rent use of alcohol. In the United States, most alco- ory. In M. Galanter (Ed.), Recent developments in holics are very poor husbands and fathers or wives alcoholism: Treatment research, Vol. 7, pp. 67–89. and mothers; on the job, they falter and disappoint New York: Plenum Press. their coworkers. In addition, their unreliable be- MADSEN, W. (1974). The American alcoholic. Spring- havior makes for doubts and confusion in intimate field, IL: Charles C. Thomas. friendships. In sum, drinking behavior that signifi- RUDY, D. R. (1986). Becoming alcoholic: Alcoholics cantly damages the performance of basic roles is Anonymous and the reality of alcoholism. Carbon- the phenomenon, and it is not necessarily a disease dale: Southern Illinois University Press. as AA claims. Calahan and Room (1974) reported TRICE, H. M. (1966). Alcoholism in America. New York: significant correlations between heavy drinking McGraw-Hill. and impairments in the performance of these ele- TRICE, H. M. (1957). A study of the process of affiliation mentary roles. Such a definition opens the door for with Alcoholics Anonymous. Quarterly Journal of other therapies that assume that moderate drinking Studies on Alcohol, 18, 39–54. is possible. It even assumes that there may be TRICE, H. M., & ROMAN, P. M. (1970). Delabeling, re- ‘‘spontaneous recovery,’’ that no therapy of any labeling and Alcoholics Anonymous. Social Problems, kind may be involved in some recoveries. 17(4), 538–546. Finally, it should be noted that the Twelve Steps HARRISON M. TRICE of AA are, in many members’ minds, inevitably associated with AA’s Twelve Traditions, which are aphorisms for the maintenance and continuity of TRIPLICATE PRESCRIPTION An AA itself at the group level. Examples are: Tradi- estimated hundreds of millions prescribed medication 1—Our common welfare should come first; tion doses are diverted to the street each year. Trip- personal recovery depends upon AA unity. Tradi- licate-prescription programs were developed as an tion 10—We need always maintain personal ano- effort to decrease the diversion of prescription med- nymity at level of press, radio, and films (Alcoholics ications to illicit markets at a reduced cost of gov- Anonymous World Services, 1965). ernment investigation. States with such laws require physicians to write prescriptions on special (SEE ALSO: Alcoholism; Disease Concept of Alcohol- triplicate forms for all Schedule II drugs, including ism and Drug Abuse; Rational Recovery; Sobriety; narcotic analgesics, Barbiturates, and stimulants. Treatment, History of; Vulnerability As Cause of In 1989 New York State passed legislation re- Substance Abuse) quiring triplicate prescribing for the Benzodiaze- pines (Schedule IV substances). BIBLIOGRAPHY In triplicate prescribing, the physician keeps one ALCOHOLICS ANONYMOUS WORLD SERVICES. (1976). Alco- copy of the prescription for five years and sends two holics Anonymous: The story of how thousands of men copies with the patient to the pharmacist. The and women have recovered from alcoholism (3rd ed.). pharmacist keeps one copy and forwards the third New York: A.A. Publishing. to a specified state agency. Here the prescription is ALCOHOLICS ANONYMOUS WORLD SERVICES. (1965). used to track the physician’s prescribing practices Twelve steps and twelve traditions. New York: Au- and the patient’s use of the controlled substances. thor. With some exceptions, refills are not permitted for ALCOHOLICS ANONYMOUS WORLD SERVICES. (1939). Alco- medications prescribed under this system. holics Anonymous (1st ed.). New York: Author. Opponents of the triplicate-prescription system ARMOR, D. J., POLICH, J. M., & STAMBUL, H. B. (1976). claim that although it is effective in decreasing Alcoholism and treatment. Santa Monica, CA: Rand. diversion, it does so at the expense of some patients BALES, R. F. (1962). The therapeutic role of Alcoholics who are unjustly denied analgesics, anxiolytics, or Anonymous as seen by a sociologist. In D. Pittman & sedative-hypnotics. The New York experience with 1268 TWELVE STEPS, THE

triplicate prescribing of benzodiazepines is often BIBLIOGRAPHY considered an example of this. Although benzodiazepine prescriptions were reduced by up to 60 AMERICAN MEDICAL ASSOCIATION COUNCIL ON SCIENTIFIC percent, the number of prescriptions for the older AFFAIRS. (1995). Aspects of pain management in and potentially more hazardous sedatives (such as Adults. Journal of the American Medical Association. MEPROBAMATE, methyprylon, ETHCHLORVYNOL, AMERICAN MEDICAL ASSOCIATION COUNCIL ON SCIENTIFIC butalbital, and CHLORAL HYDRATE) increased AFFAIRS. (1982). Drug abuse related to prescribing markedly—in contrast to continued decreases in practices. Journal of the American Medical Associa- prescribing them in the rest of the United States. tion, 247(6), 864–866. New York also required that any physician who BRAHAMS, D. (1990). Benzodiazepine overprescribing: prescribed an applicable drug for a long term pe- Successful initiative in New York State. Lancet, 336, riod was required to report the patient as a drug 1372–1373. ‘‘addict’’ or ‘‘habitual user,’’ a notion the doctors NEW YORK STATE PUBLIC HEALTH COUNCIL, Report to the found unsettling, especially when the drug was pre- commissioner of health, Breaking down the barriers to scribed for maladies like cancer. The American Medical Association called the practice of triplicate pain management: recommendations to improve the prescriptions no less than ‘‘intimidation by regula- assessment and treatment of pain in New York State, tory and law enforcement agencies’’ (Report 4). It January 1998. was viewed as so intimidating by New York doctors TEXAS DEPARTMENT OF PUBLIC SAFETY. Triplicate that 82 percent of the doctors surveyed in 1998 did Prescription Program. Available: http:// not use the drug deemed most appropriate because www.txdps.state.tx.us. [12 September 2000]. of the observation of regulators. WEINTRAUB, M., ET AL. (1991). Consequences of the In 1990 an attempt to federally legislate tripli- 1989 New York State triplicate benzodiazepine pre- cate prescriptions for Schedule II medications for scription regulations. Journal of the American Medi- all states was unsuccessful in the House of Repre- cal Association, 266(17), 2392–2397. sentatives, but efforts in some states, like Texas, to WILFORD, B. (1991). Prescription drug abuse: Some con- develop an electronic method of gathering the in- siderations in evaluating policy responses. Journal of formation may, and is likely to phase out the triplicate prescription for a tighter method of control Psychoactive Drugs, 23(4), 343–348. there. In the State of New York, some effort is being MYROSLAVA ROMACH made to remove the triplicate prescription system KAREN PARKER for a single ofﬁcial system that is intended to be less REVISEDBY ANDREW J. HOMBURG intimidating, although there is no evidence to how successful it will be.

(SEE ALSO: Controls: Scheduled Drugs/Drug Sched- ules, U.S.; Iatrogenic Addiction; Legal Regulation TWELVE STEPS, THE See Treatment: of Drugs and Alcohol; Multidoctoring) Twelve Step Facilitation U

UKAT: U. K. ALCOHOL TREATMENT vidually based cognitive and behavioral programs, TRIAL Everyone has a view about the nature the one focusing on behavior change and the other and remedy of ADDICTION disorders, most likely focusing on motivational change. All were found to because so many of these behaviors are visible in be equally good at helping people with ALCOHOL the public domain. Moreover they are common, so dependence and problems to give up or reduce their everyone knows someone who has one. As a result, drinking (Project MATC11, 1997). things done in the name of treatment are sometimes In the U.K., treatment for problem drinking and based in science and sometimes they have more to dependence has taken a somewhat different course: do with folklore. the twelve step approach to recovery, while practiced in Alcoholics Anonymous, is not the most BACKGROUND common form of or basis for treatment. Most treatment agencies in the U.K. are provided by the state Many treatments of drinking problems have and based in the cognitive behavioral approach. been presented over the years, some have endured Moreover, the pursuit of moderation drinking goals due to the scientific evidence for their efficacy, but for those with mild to moderate levels of alcohol many have endured because of their popularity and dependence and an absence of alcohol related in spite of the paucity of evidence for their effec- physical harm is common. Controlled drinking tiveness. A handbook of treatments shown to be practice is prescribed for a minority of patients in effective, with ratings of their effectiveness from most treatment agencies. A further consideration clinical trials as well as clinical descriptions of the leading up to the present study was the growing method of their delivery was published during the recognition of the central role of the social network nineties (Miller and Ilester, 1995): following on in supporting change in people with alcohol and front this a large study was conducted in the U.S., drug problems. It has increasingly become common which aimed to answer the question of whether one practice in the U.K. to recruit family members and treatment was better than another for certain sorts significant others in the process of treatment of people (for example those who were socially (Orford, 1994). stable, mentally ill, committed to entering treat- In light of these considerations, the Medical Re- ment). Three treatments were compared in the at- search Council in Britain agreed to fund a multi- tempt to answer this question and one of these center study of treatments for drinking problems. involved encouraging clients to enter TWELVE STEP The Principal Investigators, a mixture of National recovery programs in the form of ALCOHOLICS Health Service and University based clinicians and ANONYMOUS. The other two treatments were indi- researchers have collaboratively designed and im-

1269 1270 UKAT: U. K. ALCOHOL TREATMENT TRIAL plemented the study. Results will be available in they have contact with someone in the community the year 2002. and are deemed possible to trace after treatment is complete, at three months and at one year. This DESIGN requirement tends to exclude only those who are rootless and not in regular contact with any other The UKATT study compares two treatments to agency. Also excluded are those who have already determine their relative effectiveness: Motivational been treated as part of the study, the goal is to Enhancement Therapy, adapted from the treat- identify the effects of a single dose of the treatment ment studied in Project MATCH (Miller et al. rather than repeated doses. 1992), is treatment which targets the motivation of Once they have been accepted for the study, the individual for drinking and for stopping or re- clients are given a battery of tests and question- ducing drinking. Using feedback of objectives tests naires designed to measure their drinking, related which are run as part of the assessment procedure, psychological and physical health, their use of the therapist uses specific techniques which have health and other social services, their social net- been shown to enhance client motivation for works, the extent to which there is drinking in change. The content of sessions is discussion of the these, their daily activities and whether these in- negative consequences of continuing to drink in a volve, their motivational stage of change and readi- harmful fashion and of the benefits of change. The ness for treatment. Clients are than randomly as- treatment with which MET is compared is Social signed to one of the two treatments which Behavior and Network Therapy whose focus is net- commences forthwith. Where there is a preliminary work support for change. Treatment sessions con- requirement for medically supervised withdrawal centrate on the recruitment of social network whose from alcohol or the need for another physical or members are than encouraged to modify their social intervention, the above assessment will be coping responses, improve lines of communication deferred until this has been achieved. with the client, assist in the development of a re- An important goal of the study is to be prag- lapse prevention program including identification matic in order that the findings are relevant to the of alternative activities and further sources of sup- average treatment agency in the U.K. Relevance port. This treatment is adapted from a number of would mean that the treatments could be offered as sources, primarily the Community Reinforcement the standard treatments for alcohol dependence Approach (Hunt and Azrin 1973) and Network and problem drinking by those staff normally re- Therapy (Galanter 1993). Both treatment proto- cruited to work in such agencies. Therapists for the cols are specified in manual form and supervision study are therefore existing employees at the clini- of therapy, conducted by telephone and simulta- cal sites participating in the study. They are invited neous viewing of videos, is designed to ensure man- to express an interest in becoming a study therapist ual adherence. and to submit a resume and video recording of their Clients for the study are recruited at the partici- practice for selection. If deemed suitable they are pating clinical centers, which are a combination of also randomly allocated to be trained in one or the National Health Service and counseling agencies other treatment. They are unable to select the treat- for the treatment of alcohol dependence. The clini- ment that they will be delivering in the study. The cal sites are in three different parts of the country: purpose of this procedure is to address the question Yorkshire, South Wales, and the Midlands. The of whether it is the case that any therapist with the goal is to include as many as possible of the clients above qualifications can be taught to deliver these normally treated in these agencies and therefore the treatments. exclusion criteria have been kept to a minimum. The therapists normally have professional quali- People with active mental health problems or with fications in nursing, medicine, social work, occupa- addiction to a different treatment. Those younger tional therapy or counseling and at least two years than sixteen are not included: they have to be seen experience working with clients with drinking with a responsible adult other than the therapist problems. They attend a three-day introduction to and this would interfere with the individual nature the therapy to which they have been assigned and of one of the treatments. Homeless people are not this takes place at the national training center in excluded provided that they can demonstrate that Leeds in Yorkshire. Thereafter they are required to UNITED NATIONS CONVENTION AGAINST ILLICIT TRAFFIC IN NARCOTIC DRUGS 1271

practice and demonstrate competence by objective BIBLIOGRAPHY pre-determined criteria with at least two cases be- GALANTER, M. (1993). Network therapy for alcohol and fore proceeding to offer treatments in the study. drug Abuse: A new approach in practice. New York: All therapy sessions are video recorded for the Basic Books Inc. purpose of supervision, standardization of the de- HESTER, R. K., and MILLER, W. R. (eds.). (1995). Hand- livery of treatment and evaluation of the extent to book of alcoholism treatment approaches: Effective which these things have occurred. alternatives. Needham Heights, MS: Allyn and Bacon. HUNT, G. and AZRIN, N. (1973). The community rein- OUTCOMES forcement approach to alcoholism. Behaviour Re- search and Therapy,11 , 91–104. The effectiveness of the two treatments is judged MILLER, W. R., ZWEBEN, A., DICLEENTE, C. C. and on the basis of the amount and frequency of drink- RYCHTARIK, R. G. (1992). Motivational enhancement ing, the level of dependence and alcohol related therapy manual: A clinical research guide for thera- problems in the study clients at three months and at pists treating individuals with alcohol abuse and de- twelve months. Measures of quality of life, eco- pendence. Project MATC11 Monograph Series No. 2. nomic activity, psychiatric morbidity and adjust- Rockville, MD: NIAAA. ment are also used to assess the value of the treat- OXFORD, J. (1994). Empowering family and friends: a ments. new approach to the prevention of alcohol and drug Qualitative data on the process of therapy and problems. Drug and Alcohol Review,13 , 417–429. PROJECT MATC11 RESEARCH GROUP. (1997). Matching the perceptions of the client and therapist of the alcoholism treatments to client heterogencity: Post active ingredients of the treatments are collected treatment drinking outcomes. Journal of Studies of through a number of instruments administered at Alcohol,58 , 7–29. the end of the therapy sessions and the quality of GILLIAN TOBER the deliver of the treatment is separately assessed through independent ratings of therapist performance as demonstrated in the video recordings or practice. Integrity of the treatments as well as indi- U.S. DRUG POLICY See Anslinger, Harry G., and U.S. Drug policy; U.S. Government/U.S. vidual variations between therapists are identiﬁed Government Agencies through this method off evaluation.

CLINICAL IMPLICATIONS U.S. DRUG UNDERCOVER OPERA- There is an increasing demand for time limited TIONS See Drug Interdiction treatments of alcohol dependence, for standardization and transparency of practice. While it is well recognized that there are therapist behaviors which UNITED NATIONS CONVENTION are associated with improved outcomes in clients AGAINST ILLICIT TRAFFIC IN NAR- and these behaviors are often expressed in rather COTIC DRUGS AND PSYCHOTROPIC individual ways, it is also recognized that too often SUBSTANCES, 1988 This international treaty was intended to extend and augment the agree- the question of the duration and nature of treatments among the signatories that were contained in ment is based upon the personal preference of the the 1961 SINGLE CONVENTION ON NARCOTIC DRUGS therapist and therefore subject to a variety of overt and the 1971 CONVENTION ON PSYCHOTROPIC SUB- and convert inﬂuences. That therapists with a wide STANCES. The 1988 Convention came into force in variety of backgrounds and different working prac- November 1990. By November 1994, 103 govern- tices can be taught to adhere to a manual and to ments and the European Economic Community deliver treatments in line with protocols has been had been parties to the Convention. Included demonstrated during this trial. How effective their among the provisions are arrangements and agree- interventions will be revealed in the results. ments to legalize seizure of drug-related assets; 1272 U.S. GOVERNMENT

criminalize MONEY LAUNDERING; relax bank-se- ment (ODALE), the Office for National Narcotic crecy rules; permit extradition of individuals Intelligence, and U.S. Customs Service activities charged with drug-law violations; control ship- primarily directed to drug law enforcement. Since ments of precursor and essential chemicals; con- that time, DEA has been the lead federal agency for tinue to support CROP CONTROL and eradication; enforcement of drug laws. and share evidence with law enforcement and pros- DEA operates domestically and in foreign coun- ecuting agencies of governments who are party to tries with the agreement of the government in each the conventions. country. Its legal authority stems primarily from the CONTROLLED SUBSTANCES ACT and other laws BIBLIOGRAPHY directed at control of essential chemicals and precursors. DEA’s efforts are directed against illicit U.S. DEPARTMENT OF JUSTICE,OFFICE OF JUSTICE PRO- drug production and high level drug-smuggling GRAMS,BUREAU OF JUSTICE STATISTICS. (1992). Drugs, and drug-trafficking organizations operating crimeandthejusticesystem(December NCJ- within the United States or abroad. This agency is 133652). Washington, DC: U.S. Government Printing responsible for working with foreign governments Office. to identify and disrupt the cultivation, processing, JEROME H. JAFFE smuggling, and distribution of illicit substances, and the diversion of legally manufactured pharma- ceuticals to illicit traffic in the United States. It U.S. GOVERNMENT The following articles maintains formal relationships with INTERPOL appear in this section: and the United Nations and works with them on Agencies in Drug Law Enforcement and international narcotics-control programs. The U.S. Supply Control; Department of State also has major responsibilities Agencies Supporting Substance Abuse in working with foreign governments in this aspect Prevention and Treatment; of drug-traffic control. In carrying out these activi- Agencies Supporting Substance Abuse ties, DEA works closely with the state department, Research; the Coast Guard, the Internal Revenue Service, and Drug Policy Offices in the Executive Office of the U.S. Customs Service, and also with state and the President; local law-enforcement agencies. The Organization of U.S. Drug Policy One of DEA’s major domestic responsibilities is the enforcement of regulations concerning importation, manufacture, storage, and dispensing of all Agencies in Drug Law Enforcement and drugs scheduled under the Controlled Substances Supply Control So many agencies are involved Act. Related to this function is the oversight, autho- in drug law-enforcement and supply-control activi- rized by the Drug Treatment Act of 1974, of drug ties that none are discussed here in detail. Except treatment programs using such drugs as LAAMor for the Drug Enforcement Agency (DEA), the order METHADONE (in METHADONE MAINTENANCE). DEA in which these descriptions appear is not necessar- employs approximately 400 administration com- ily related to the importance of an agency’s role in pliance officers to enforce regulations dealing with the overall supply-control effort: Their functions production and distribution of PRESCRIPTION frequently fit together like parts of an intricate DRUGS and supports a training program for narcot- puzzle. ics officers at state and local levels. Virtually all The DEA was created in 1973 as a result of a state legislatures have passed a version of a proto- reorganization that merged the activities and per- type law, the Uniform Controlled Substances Act, sonnel from four federal drug law-enforcement which places legal CONTROLS on drugs at the state programs into one agency within the Department of level similar to those at the federal level and estab- Justice (DOJ). John Bartels, Jr., was the first direc- lishes penalties under state law for violation of tor. The offices and programs merged into DEA those laws. The Uniform Controlled Substances Act were the Bureau of Narcotics and Dangerous Drugs promotes uniformity in the way drugs are regu- (BNDD), the Office for Drug Abuse Law Enforce- lated, but individual states may schedule drugs not U.S. GOVERNMENT: Agencies in Drug Law Enforcement and Supply Control 1273 included in federal schedules and may place any for drug law enforcement. Some goes into a special drug at a different level of scheduling. forfeiture fund within the Office of National Drug Because of similar laws at the federal and state Control Policy (ONDCP), which in turn transfers it levels, and overlapping responsibilities among fed- to other federal agencies. For example, significant eral agencies, several law-enforcement agencies amounts were transferred to the Center for Sub- may have jurisdiction with respect to any single stance Abuse Treatment (CSAT) to support treat- drug offense or group of offenders. The decision ment programs for pregnant addicts. about which of the cooperating agencies takes the In addition to DEA, several other organizations lead and under which law a case will be tried de- within the DOJ and other Cabinet departments pends on mutual assessment among enforcement have responsibility in areas concerning drug laws agencies and prosecutors of their capabilities and and related matters. The Office of Justice Programs procedures, and of which jurisdiction is most likely (OJP) in the DOJ, established by the Justice Assis- to obtain a conviction, since rules of evidence and tance Act of 1984, contains several bureaus in- procedures differ between federal and local courts. volved with these issues. Three having significant Generally, federal agencies will focus on high level roles at the present time are the Bureau of Justice drug traffickers and networks. Local police are em- Assistance (BJA), the Bureau of Justice Statistics powered only to enforce state and local drug laws (BJS), and the National Institute of Justice (NIJ). and are not permitted to arrest people for breaking The BJA provides technical and financial assistance a federal drug law. Federal agents may not enforce to state and local government for controlling drug state and local drug laws unless specifically autho- trafficking and violent crime. Under the terms of rized to do so. The DEA also has enforcement re- the Anti-Drug Abuse Act of 1988, states may apply sponsibilities under the Chemical Diversion and for grants to assist them in enforcing local and state Trafficking Act of 1988. This law was designed to laws against offenses comparable to those included control the availability of chemicals and precursors in the Controlled Substances Act. Part of the appli- used by clandestine laboratories to produce DE- cation for these ‘‘formula grant’’ funds requires SIGNER DRUGS or to further process plant products devising a statewide anti-drug and -violent crime such as COCA leaf into pure COCAINE. Since at least strategy. The BJS collects, analyzes, and dissemi- thirty-seven states have passed similar laws, this is nates information on crime, its victims, and its per- another area where federal and local enforcement petrators. Its 1992 report, Drugs,Crime,and the agencies may have concurrent jurisdiction. Justice System, the source for much of the material Other major responsibilities of DEA include in- in this article, may be the best written and most vestigation of major drug traffickers operating at comprehensive summary on the topic ever pro- interstate and international levels; personnel train- duced by the federal government. BJS also manages ing; scientific research related to control or preven- the Drugs and Crime Data Center and Clearing- tion of illicit trafficking; management of a narcotics house (tel. 1-800-666-3332), which gathers and intelligence system; seizure and forfeiture of assets evaluates existing data on drugs and the justice derived from or traceable to illicit drug trafficking. system. The NIJ is the major research and develop- Forfeiture is the loss of ownership of property ment entity within the DOJ. Among its other activi- used in connection with drug-related criminal ac- ties, NIJ evaluates the effectiveness of programs tivity or property derived from its income. Such supported by BJA, such as community anti-drug forfeiture was authorized in the Comprehensive initiatives, and SHOCK INCARCERATION AND BOOT- Drug Prevention Control Act of 1970 and the CAMP PRISONS. Racketeering Influenced and Corrupt Organization Other drug law-enforcement entities within the (RICO) Statute also passed in 1970. In 1990, DEA DOJ include the Federal Bureau of Investigation seized assets valued at more than one billion dol- (FBI); the U.S. Attorneys, who are the chief federal lars, although not all of this property was ulti- law-enforcement officers in their districts and are mately forfeited. Forfeited property is usually sold responsible for prosecuting cases in federal court; at public auction and the proceeds are used for the Immigration and Naturalization Services (INS); government activities and shared with cooperating and the U.S. Marshals Service, which manages the state governments. States have used these funds for Asset Forfeiture Fund. The FBI became more drug treatment and education programs as well as prominently involved in antidrug activities when its 1274 U.S. GOVERNMENT: Agencies in Drug Law Enforcement and Supply Control resources were significantly expanded in 1982 un- vant laws to U.S. officials serving in foreign coun- der President Ronald W. Reagan’s reinvigoration of tries. the ‘‘war on drugs.’’ At that time it was given The Department of Defense (DOD) is involved concurrent jurisdiction with DEA to investigate in detecting and monitoring aircraft and ships that drug offenses, with the FBI concentrating primarily might be involved in smuggling drugs into the on drug trafficking by organized crime, electronic United States. Until the 1980s, the military was surveillance techniques, and drug-related financial prohibited from exercising police power over U.S. activities such as investigations of international civilians by the Possae Comitatus Act of 1876. MONEY LAUNDERING. Changes in the act allow the military to share Treasury Department agencies that play a role resources with civilian law-enforcement agencies, in controlling illicit drugs include the U.S. Customs although military personnel are still not permitted Service, which stops and seizes illegal drugs as well to arrest civilians. The National Guard also assists as other contraband being smuggled into the federal agencies in border surveillance and in mari- United States; The Bureau of Alcohol, Tobacco, juana eradication. and Firearms (BATF), which investigates viola- Eleven agencies are involved in the Intelligence tions of laws dealing with weapons, particularly Center at El Paso, Texas (EPIC), operated by the federal drug offenses invoking weapons; and the DEA. EPIC is designed to target, track, and in- Internal Revenue Service (IRS), which assists in terdict drugs, aliens, and weapons moving across financial investigations, particularly money laun- U.S. borders. The participating agencies, in addi- dering. tion to the DEA, are the Federal Bureau of Investi- Two agencies in the Department of Transporta- gation (FBI); the Immigration and Naturalization tion, the Federal Aviation Administration (FAA) Service (INS); the Customs Service; the U.S. Mar- and the U.S. Coast Guard, are significantly in- shals Service; the U.S. Coast Guard; the Federal volved in drug-control activities. The FAA uses its Aviation Administration (FAA); the Secret Service; radar systems to assist in detecting smuggling by the Department of State Diplomatic Service; the air; the Coast Guard is involved in interdiction of Bureau of Alcohol, Tobacco and Firearms (BATF); drugs being smuggled into the U.S. by water. and the Internal Revenue Service (IRS). There is The Postal Inspection Service of the U.S. Postal also a Counternarcotics Center developed by the Service is also involved in the antidrug effort. This Central Intelligence Agency (CIA) that coordinates agency enforces laws against using the mail to international intelligence on narcotics trafficking. transport drug paraphernalia and illegal drugs. This effort involves personnel from the National The Department of State’s role in international Security Agency (NSA), the Customs Service, the drug policy is to coordinate drug-control efforts DEA, and the Coast Guard. with foreign governments. Within State, the Bureau of International Narcotics Matters (INM) is respon- (SEE ALSO: Crime and Drugs; Drug Interdiction; sible for international antidrug policy. This bureau International Drug Supply Systems; Terrorism and provides technical assistance, money, and equip- Drugs) ment to foreign governments for local law enforcement, transportation of personnel, and equipment BIBLIOGRAPHY for crop eradication. It also monitors worldwide drug production. Each U.S. Embassy abroad has a BUREAU OF JUSTICE STATISTICS,OFFICE OF JUSTICE PRO- designated narcotics coordinator. In countries GRAM, U.S. DEPARTMENT OF JUSTICE. (1992). Drugs, where there is considerable drug-related activity, crime,and the justice system . Washington, DC: U.S. there may be an entire narcotics-assistance section Government Printing Office. at the embassy. The state department also helps DRUG ABUSE POLICY OFFICE,OFFICE OF POLICY DEVELOP- selected foreign governments with demand-reduc- MENT,THE WHITE HOUSE. (1984). National strategy tion activities. Helping countries adversely affected for prevention of drug abuse and drug trafficking. economically by drug CROP CONTROL and eradica- Washington, DC: U.S. Government Printing Office. tion is a responsibility of the Agency for Interna- EXECUTIVE OFFICE OF THE PRESIDENT,THE WHITE HOUSE. tional Development. The U.S. Information Agency (1995). National drug control strategy. Washington, provides information about drug policy and rele- DC: U.S. Government Printing Office. U.S. GOVERNMENT: Agencies Supporting Substance Abuse Prevention and Treatment 1275

OFFICE OF THE FEDERAL REGISTER,NATIONAL ARCHIVES tered within SAMHSA served to refocus NIDA’s AND RECORDS ADMINISTRATION. (1993). United States role on the generation of knowledge through scien- government manual 1993/1994. Washington, DC: tific research, so that more could be learned about U.S. Government Printing Office. strategies and programs to help prevent and treat JEROME H. JAFFE drug abuse. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducts research on alcohol abuse and alcoholism. Because a comprehensive Agencies Supporting Substance Abuse approach to prevention and treatment of drug Prevention and Treatment Within the U.S. abuse requires attention to alcohol as well as to Department of Health and Human Services illicit drugs, and because individuals who abuse (DHHS), originally established in 1953 as the De- illicit drugs often abuse alcohol as well, the re- partment of Health, Education, and Welfare search programs of NIDA and NIAAA are symbi- (DHEW), a number of Public Health Service otic. Furthermore, the genetic, environmental, and (PHS) agencies have been involved in reducing social influences important to the initiation of drug drug abuse. From 1974 to 1992, many demand- and alcohol use are similar, and research in one reduction activities have related to increasing, area suggests researchable hypotheses in the other. through research, the scientific foundations for a The Center for Substance Abuse Prevention better understanding of how drugs of abuse inter- (CSAP), established in 1986 as the Office for Sub- act with individuals, so as to prevent drug abuse stance Abuse Prevention (OSAP), has led the na- and effectively treat those who do abuse drugs. tion’s efforts to prevent alcohol and other drug use, Included among these agencies are the National with a special emphasis on youth and FAMILIES at Institute on Drug Abuse (NIDA) and the National particularly high risk for drug abuse. Youth consid- Institute on Alcohol Abuse and Alcoholism ered to be at high risk include school DROPOUTS, (NIAAA), both components of the National Insti- economically disadvantaged youth, or children of tutes of Health (NIH), as well as the Center for parents who abuse drugs or alcohol or who are at Substance Abuse Prevention (CSAP) and the Cen- high risk of becoming drug or alcohol abusers. ter for Substance Abuse Treatment (CSAT), com- CSAP administers a variety of programs, including ponents of the Substance Abuse and Mental Health Prevention demonstration grants targeting youth at Services Administration (SAMHSA). In addition, high risk and projects for pregnant and postpartum the Health Resources and Services Administration women and their infants. (HRSA) and the National Institute of Child Health The Center for Substance Abuse Treatment and Human Development (NICHD), another NIH (CSAT), formerly the Office of Treatment Improve- component, play a role in the department’s anti- ment (OTI), was established administratively in drug abuse mission. Although not all inclusive, the 1990 with a focus on improving treatment services chart below shows the organizational hierarchy of and expanding the capacity for delilvering treat- these agencies within the department. ment services. In addition to administering the Al- From its creation in 1974 by statute, the Na- cohol and Drug Abuse block grant, CSAT adminis- tional Institute on Drug Abuse has conducted RE- ters a number of demonstration grant programs SEARCH on drugs of abuse and their effects on indi- such as the Target Cities, Critical Populations, and viduals. In its early days, NIDA supported Criminal Justice treatment programs. PREVENTION and TREATMENT programs and con- Drug and alcohol abuse are complex behaviors ducted clinical training programs for professional that often result in a multitude of adverse conse- health-care workers (particularly in schools of quences. Thus, to understand them necessitates medicine, nursing, and social work) and counselor multifaceted, often crosscutting areas of research. and other paraprofessional training. With the ad- Because many individuals who suffer from alcohol vent of the Alcohol and Drug Abuse and Mental or drug abuse also suffer from mental illness, Health Services block grant, enacted into statute in NIAAA and NIDA, as well as the National Institute 1981, the direct provision of treatment and preven- of Mental Health (NIMH) of the NIH, are engaged tion services became a state responsibility. Enact- in initiatives to learn more about individuals who ment of the block grant that is currently adminis- are dually diagnosed. 1276 U.S. GOVERNMENT: Agencies Supporting Substance Abuse Research

Acquired immunodeficiency syndrome (AIDS) BIBLIOGRAPHY has become a growing health program among in- CHAISSON, R. E., ET AL. (1987). Human immunodefi- travenous drug users, and an increased risk of hu- ciency virus infection in heterosexual intravenous man immunodeficiency virus (HIV) infection in drug users in San Francisco. American Journal of those who share drug paraphernalia with other Public Health,77 (2), 169–172. drug users has been clearly demonstrated (Chais- SCHOENBAUM, E. E., ET AL. (1989). Risk factors for hu- son et al., 1987; Schoenbaum et al., 1989). Accord- man immunodeficiency virus infection in intravenous ingly, NIDA collaborates with the Centers for Dis- drug users. New England Journal of Medicine, ease Control (CDC) on AIDS prevention programs 321(13), 874–879. and with the National Institute of Allergy and In- RICHARD A. MILLSTEIN fectious Diseases (NIAID) to provide HIV therapeutics to intravenous drug abusers with HIV. The study of maternal and fetal effects of drug Agencies Supporting Substance Abuse abuse is another high-priority focus within the de- Research In the United States, federal support partment. Research and demonstration programs of drug-abuse research began in the 1920s with the have been undertaken by NIDA and CSAP, and the work of Lawrence Kolb. It became more formalized NICHD is also conducting studies in this area. with the establishment of the Addiction Research Recent research has shown that the most effec- Center in 1935. A small research unit was formed with only fifteen employees in a U.S. Public Health tive treatment for drug abusers is a comprehensive Service Hospital in Lexington, Kentucky, by 1944. array of services that address not only their drug- The Addiction Research Center was designed for abuse problems but also other health problems and federal prisoners who were narcotics addicts. This their potential need for education and vocational research group became part of the National Insti- rehabilitation, as well as a host of ancillary services. tute of Mental Health (NIMH) in 1948, the year the Accordingly, NIDA, the centers within SAMHSA, institute was established. In 1979, the Addiction and HRSA are exploring the effectiveness of pro- Research Center moved to Baltimore, Maryland, viding a comprehensive range of drug-abuse and and became the in-house (intramural) research other primary-care services, both in drug-abuse program of the National Institute on Drug Abuse settings and primary-care settings. (NIDA), which was itself established by Congress in Besides the DHHS, there are many other agen- 1974. cies involved in prevention and treatment efforts. In the early 1990s, it was estimated that NIDA funded 88 percent of the drug-abuse research in For example, the Food and Drug Administration the world. In 1992, the NIDA budget for the almost (FDA), plays a determining role in deciding when 1,000 research grants awarded to universities and new pharmacological treatment agents can be mar- other research institutions (i.e., extramural re- keted for clinical use, and it is one of the key search) totaled 338 million dollars. NIDA’s 1992 agencies setting policies and standards for the use intramural research budget for the Addiction Re- of OPIOID drugs in the treatment of opioid depen- search Center was 24 million dollars. The research dence. Both the Department of Education and the thus funded includes studies in practically every Department of Justice (through the Drug Enforce- basic and clinical science, both biomedical and so- ment Agency [DEA]) have significant programs cial. The National Institute on Alcohol Abuse and aimed at prevention; the Department of Veterans Alcoholism (NIAAA), established in 1970, con- Affairs and the Department of Defense (U.S. MILI- ducts parallel efforts in the area of alcohol-abuse research. In 1992, its budget for extramural re- TARY) have also made major commitments to search was 155 million dollars for over 600 re- treatment. search projects. NIAAA’s intramural research arm, located in Bethesda, Maryland, had a budget of (SEE ALSO: Education and Prevention; Prevention nearly 20 million dollars. Movement; Research; Substance Abuse and HIV/ Both NIDA and NIAAA became part of the Na- AIDS) tional Institutes of Health (NIH) in October 1992. U.S. GOVERNMENT: Agencies Supporting Substance Abuse Research 1277

They had previously been part of the Alcohol, Drug and the toxic effects of alcohol have been conducted Abuse, and Mental Health Administration (AD- by researchers based at Veterans Administration AMHA), which included both research and services (VA) hospitals and funded in part by research components. By separating these two components, funds from the Department of Veterans Affairs. the Congress indicated its intention to give proper Other federal agencies have a regulatory role in emphasis to both. Now treatment and prevention certain types of drug-abuse research. Many of the services for alcohol and drug abuse are under the drugs that are studied in animals and volunteer direction of the Substance Abuse and Mental human subjects are included under the CON- Health Services Administration (SAMHSA). TROLLED SUBSTANCES ACT of 1970. In order to NIDA and NIAAA are the two largest federal obtain and store the drugs, researchers must be research institutes dedicated to drug abuse and al- properly registered with the Drug Enforcement cohol research, but there are many other agencies Agency (DEA). The DEA is also responsible for that have a stake in these areas. They include other ensuring that the drugs are properly stored and the institutes in the National Institutes of Health; for records of their use are properly kept by the re- example, the National Institute of Child Health and searchers. In addition, researchers who are interes- Development centers its research on the effects of ted in studying any drug not yet approved for clini- drugs and alcohol on fetal development and on the cal use, or studying an approved drug for a new use consequences for the neonate of exposure to drugs (such as using the antihypertensive agent, CLONI- and alcohol during pregnancy. The National Insti- DINE, to control alcohol, tobacco, or opioid with- tute of Mental Health conducts research on the high drawal), must obtain permission obtaining an In- coincidence of mental illness and substance-abuse vestigational New Drug (IND) authorization from disorders. Some of the other institutes have simi- the Food and Drug Administration (FDA). Further, larly targeted interests, as, for example, the Na- when a new agent seems promising, a sponsor (usu- tional Cancer Institute, which played an important ally a pharmaceutical company) must submit the role in support of research on tobacco dependence data supporting its safety and effectiveness to the and the adverse health effects of tobacco. FDA before it can be approved for marketing and Other parts of the Public Health Service also general use. play a role in substance abuse research. The Cen- Both the Department of Justice and the Depart- ters for Disease Control (CDC) use their epidemio- ment of the Treasury are concerned with law en- logical expertise to resolve certain questions about forcement issues surrounding drug and alcohol use, the nature and extent of the abuse of drugs and and they have funded research on detection of clan- alcohol. The Agency for Health Care Policy and destine laboratories and the nature of DESIGNER Research conducts research on the costs associated DRUGS. The 1994 National Strategy showed that of with medical care and health insurance for drug the entire federal drug-abuse research budget, and alcohol abusers seeking treatment. some 500 million dollars, approximately 67 million Beyond the Public Health Service and the De- was allocated to domestic law-enforcement re- partment of Health and Human Services, many search. other federal agencies and departments are con- The Department of State and the Department of cerned with and conduct research on the social Defense are involved in matters relating to interna- problems caused by drug and alcohol abuse: the tional narcotics control. The U.S. Information departments of education, labor, transportation, Agency (USIA) and the Agency for International treasury, justice, state, veterans affairs and even Development sponsor small drug-abuse research defense—each has a stake in drug-abuse research. programs, mostly epidemiological in nature, in var- The Department of Education is concerned primar- ious countries. The Office of National Drug Control ily with drug and alcohol prevention; the depart- Policy (ONDCP) was given the mandate by Con- ments of labor and transportation with workplace gress in 1988 to coordinate the federal antidrug- performance impaired by drugs and alcohol. abuse effort. It does this through its budgetary The Department of Veterans Affairs has played oversight and through the Research, Data, and an important role in both basic and clinical re- Evaluation Committee. The ONDCP for several search. Some of the most important work on the years has had a Science and Technology subcom- treatment of opioid dependence and on alcoholism mittee, which oversees the Counter-Drug Technol- 1278 U.S. GOVERNMENT: Drug Policy Offices in the Executive Office of the President ogy Assessment Center (CTAC). CTAC is involved Offices. Federal Drug Management (Office of in both medical research and supply-related coun- Management & Budget), 1973–1977. Drug Policy ter-drug technology development. The latter in- Office (Domestic Policy Staff), 1978–1980. Drug cludes activities such as the use of satellites for wide Abuse Policy Office (Office of Policy Development), area surveillance, non-intrusive inspections, and 1981–1989. development of information systems to permit sharing of data among criminal justice data bases. SPECIAL ACTION OFFICE FOR DRUG All of these policy-related organizations rely on ABUSE PREVENTION (SAODAP) facts based on the biomedical, epidemiological, and behavioral research funded by NIDA, NIAAA, and A separate agency in the EOP from 1971 to NIMH. 1975, SAODAP was responsible for providing leadership and coordination of all federal drug-abuse prevention activities (demand related) and to coor- (SEE ALSO: Addiction Research Unit (U.K.); Educa- tion and Prevention; Prevention Movement; dinate the demand-related activities with the sup- Wikler’s Pharmacologic Theory of Drug Addiction) ply-related efforts of law enforcement agencies. Directors. Jerome H. Jaffe, 1971–1973 (also Consultant to the President for Narcotics and Dan- BIBLIOGRAPHY gerous Drugs) Robert L. Dupont 1973–1975. EXECUTIVE OFFICE OF THE PRESIDENT. (1994). National Authorization and Role. Established by Drug Control Strategy. Washington, DC: U.S. Gov- President Richard M. Nixon (E. O. 11599, June 17, ernment Printing Office. 1971). Legislative authorization: Public Law GORDIS, E. (1988). Milestones. Alcohol Health and Re- 92-255, March 21, 1972; the ‘‘Drug Abuse Office search World,12 (4), 236–239. and Treatment Act of 1972.’’ The director reported HISTORY OF NIDA. (1991). NIDA Notes,5 (5), 2–4. to the president, working through the Domestic Council and the White House staff. SAODAP had a CHRISTINE R. HARTEL staff of over 100 and an annual budget of approximately $50 million. About 50 percent of the budget was in a ‘‘Special Fund for Drug Abuse’’ to be Drug Policy Offices in the Executive Of- transferred to other federal agencies as an incentive fice of the President The Executive Office of to develop more effective prevention programs. the President (EOP) is an administrative group of SAODAP provided oversight of all categories of key advisors and agencies supporting the president ‘‘Demand Reduction’’ functions and made recom- and the White House staff. Changes to the organi- mendations to the Office of Management and Bud- zation and functions of the EOP reflect the priori- get (OMB) on funding for drug-abuse programs. ties and interests of each president. The organiza- SAODAP published three federal strategies under tion of the EOP can be modified by executive order, the auspices of the relatively inactive Strategy by reorganization plan (when authorized), or by Council on Drug Abuse. legislation. When the authorizing statute expired on June Since 1970, several drug-policy activities have 30, 1975, SAODAP’s treatment, rehabilitation, been established in the EOP. The list includes three and prevention functions were moved from the separate EOP agencies, authorized and funded by EOP to the National Institute on Drug Abuse in the statute, and three drug-policy offices, authorized Department of Health, Education, and Welfare. by the president and located within a larger EOP agency. The drug-policy offices are listed immedi- FEDERAL DRUG MANAGEMENT, ately below, followed by a general description of OFFICE OF MANAGEMENT each’s activity. AND BUDGET Separate Agencies. Special Action Office for Drug Abuse Prevention (SAODAP), 1971–1975. Opened in 1973 as a unique office within OMB, Office of Drug Abuse Policy (ODAP), 1977–1978. Federal Drug Management (FDM) was designed to Office of National Drug Control Policy (ONDCP), manage federal activities directed at illegal drugs 1989–present. during a time of rapid expansion and major reorga- U.S. GOVERNMENT: Drug Policy Offices in the Executive Office of the President 1279 nization. FDMcontinued in operation until early functions. The director coordinated the perform- 1977. ance of drug-abuse functions by federal depart- FDM Chiefs. Walter C. Minnick, 1973–1974 ments and agencies. Edward E. Johnson, 1974–1977. ODAP, with a staff of approximately fifteen, Authorization and Role. Established by OMB conducted a comprehensive set of drug-policy re- memorandum, the authority of the staff office and views using interagency study teams. The director the budget for operating expenses were derived and staff sought a close cooperative relationship from OMB. Initially, FDM was responsible for coor- with Congress and testified when requested before dinating the implementation of drug policy, resolv- various congressional committes. The director was ing interagency disputes, assisting drug agencies required to prepare an annual report on the activi- with reorganization and management, and working ties of ODAP and to oversee the preparation of a closely with other inter-agency drug-coordinating drug-abuse strategy. structures. In August 1974, FDM’s budget and In mid-1977, the President’s Reorganization management responsibilities reverted to the normal Project prepared a reorganization of the EOP that OMB divisions and FDM continued to provide Ex- included abolishing ODAP. Congress objected to ecutive Office oversight of the domestic and international drug abuse programs, interdepartmental the loss of ODAP. After spirited congressional hear- coordination, and staff support to the cabinet coun- ings emphasizing the continuing need for executive cils on drug abuse. coordination of the drug program, ODAP was abol- Located in the Old Executive Office Building, ished in March 1978 and its responsibilities trans- FDM’s five-person staff functioned with little pub- ferred to the Domestic Policy Staff. lic visibility. Working with other OMB staff, FDM Bibliography of Associated Major Policy Publi- guided the implementation of Reorganization Plan cations (ODAP): No. 2 of 1973, including union negotiations. FDM continued through the Ford Administration, pro- U.S. Executive Office of the President. Office viding staff assistance and policy advice to OMB, of Drug Abuse Policy. Border Manage- the Domestic Council, and the National Security ment and Interdiction—An Interagency Council. FDMwas eliminated in early 1977 during Review,September 1977 . the transition to the Carter Administration. U.S. Executive Office of the President. Office of Drug Abuse Policy. Supply Control: OFFICE OF DRUG ABUSE Drug Law Enforcement—An Interagency POLICY (ODAP) Review, December 1977. U.S. Executive Office of the President. Office In March 1976, Congress authorized the Office of Drug Abuse Policy. International Nar- of Drug Abuse Policy, located in the EOP and in- cotics Control Policy,March 1978 . tended to be the successor agency to SAODAP. U.S. Executive Office of the President. Office President Gerald R. Ford did not activate the new of Drug Abuse Policy. Narcotics Intelli- agency, choosing instead to continue with the exist- gence (Classified), 1978. ing FDMstaff. President Jimmy Carter opened U.S. Executive Office of the President. Office ODAP in March of 1977 and abolished it one year of Drug Abuse Policy. Drug Use Patterns, later. The director’s office was located in the West Wing of the White House and the staff offices were Consequences and the Federal Response: in the Old Executive Office Building. A Policy Review, March 1978. Director. Dr. Peter G. Bourne, 1977–1978 U.S. Executive Office of the President. Office (also Special Assistant to the President for Health of Drug Abuse Policy. Drug Abuse Assess- Issues). ment in the Department of Defense: A Pol- Authorization and Role. Congress estab- icy Review,November 1977 . lished ODAP in Public Law 94-237 and provided U.S. Executive Office of the President. Office an annual budget of $1.2 million. The director was of Drug Abuse Policy. 1978 Annual Re- the principal advisor to the president on policies, port. Washington, DC: Government objectives, and priorities for federal drug-abuse Printing Office, 1978. 1280 U.S. GOVERNMENT: Drug Policy Offices in the Executive Office of the President

DRUG POLICY OFFICE (DPO), in March 1985 to Deputy assistant to the DOMESTIC POLICY STAFF President). Dr. Donald Ian MacDonald, 1987–1989, (Spe- The Drug Policy Office (DPO) opened March 26, cial Assistant to the President; promoted in August 1978, as an integral part of the White House Do- 1988 to Deputy Assistant to the President). mestic Policy Staff. Six people were transferred Authorization and Role. The statutory basis from ODAP, and the DPO provided direction and for the office (21 USC 1111 & 1112) required the oversight of federal drug-program activities president to establish a system to assist with drug through 1980. abuse policy functions and to designate a single Director. Lee I. Dogoloff, 1978–1980 (Asso- officer to direct the drug functions. Presidential Ex- ciate Director for Drug Policy in the Domestic Pol- ecutive Order 12368, signed on June 24, 1982, icy Staff). assigned the Office of Policy Development (OPD) to Authorization and Role. Reorganization assist the president with drug-abuse policy func- Plan No. 1 of 1977 transferred the ODAP responsi- tions, including international and domestic drug- bilities to the Domestic Policy Staff in the EOP. abuse functions by all executive agencies. The di- President Carter signed Executive Order No. 12133 rector of ODAP was responsible for advising the on May 9, 1979, formally designating the associate president on drug-abuse matters and assisting director for Drug Policy in the Domestic Policy Nancy D. Reagan and her staff in developing the Staff as First Lady’s drug-abuse prevention program. Primarily responsible for assisting the President in the performance of all those functions trans- The director and staff developed policies regard- ferred from the Office of Drug Abuse Policy and its ing all aspects of drug abuse, including drug law Director . . . in formulating policy for and in coor- enforcement, international control, and health-re- dinating and overseeing, international as well as lated prevention and treatment activities for both domestic drug abuse functions by all Executive government and the private sector. DAPO coordi- Agencies. nated the development and publication of 1982 DPO continued to report to Dr. Bourne as special and 1984 drug-abuse strategies. assistant to the president for health issues. On nu- In October 1984, Public Law 98-473, which merous occasions, the associate director testified created the National Drug Enforcement Policy before Congress on drug-policy matters. Board to oversee drug law enforcement, also in- DPO published a 1979 federal strategy under cluded a new statutory duty for DAPO; ‘‘to insure the auspices of the Strategy Council on Drug coordination between the National Drug Enforce- Abuse, an annual report in 1980, and an annual ment Policy Board and the health issues associated budget crosscut of all drug-abuse prevention and with drug abuse.’’ control activities. Both the Domestic Policy Staff In March 1987, Executive Order 12590 estab- and DPO were eliminated during the transition to lished a National Drug Policy Board (NDPB) to the Reagan Administration. assist the president in formulating all drug-abuse policy, replacing the director of DAPO in that role. The new executive order made the director a mem- DRUG ABUSE POLICY OFFICE (DAPO), ber of the NDPB and assigned DAPO to assist both OFFICE OF POLICY DEVELOPMENT the president and the NDPB in the performance of Similar in organization and responsibilities to drug-policy functions. The DAPO director assisted the preceding DPO, the Drug Abuse Policy Office in developing the health-related aspects of the na- (DAPO) was the principal EOP drug-abuse staff tional drug strategy published in the board’s 1988 during the eight years of President Ronald W. Rea- report Toward a Drug-Free America—The Na- gan’s administration. In 1981, DAPO was estab- tional Drug Strategy and Implementation Plans. lished within the White House Office of Policy De- DAPO was terminated early in the administra- velopment. tion of President George H. Bush by Public Law Directors. Carlton E. Turner, 1981–1986 100-690, which created the Office of National Drug (also Special Assistant to the President; promoted Control Policy. U.S. GOVERNMENT: Drug Policy Offices in the Executive Office of the President 1281

OFFICE OF NATIONAL DRUG Additionally, McCaffrey has pushed the U.S. Con- CONTROL POLICY (ONDCP) gress to approve an anti-drug supplemental package of more than a billion dollars to help aid the In January 1989, the Office of National Drug Colombian government in its drug interdiction ef- Control Policy (ONDCP) was established as an forts. According to McCaffrey, as quoted in a Press agency in the EOP to oversee all national drug- Release from the ONDCP, ‘‘Now ninety percent of control functions and to advise the president on the cocain on our streets and two-thirds of the her- drug-control matters. Functioning as the so-called oin seized in the U.S. originates in or passes drug czar, the director of ONDCP had the broadest through Colombia.’’ That package was passed by combination of staff, funding, and authority of any the House of Representatives in March, 2000. (ON- previous EOP drug agency or office. DCP, Press Release, 2000). Directors. William J. Bennett, 1989–1990. Bob Martinez, 1991–1992. Lee P. Brown 1993– (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- 1996. General Barry R. McCaffrey 1996–present. icy) Authorization and Role. Established by Public Law 100-690 (21 USC 1504) with a five- year authorization, ONDCP had a staff of ap- BIBLIOGRAPHY proximately 130 and a Fiscal Year 1993 budget BONAFEDE, D. (1971). White House Report/Nixon’s of- of $59 million for salaries, expenses, and support fensive on drugs treads on array of special interests. for High Intensity Drug Trafficking Areas. The National Journal,3 (27), 1417–1423. fiscal year 1994 budget request reduced the ON- DETTMER,J.&LINEBAUGH, S. (1997). McCaffrey’s DCP staff to 25 positions. In 1996, with the ap- no-win war on drugs. Insight on the News,13,no. 7 , pointment of retired Army General Barry R. Mc- 8–12. Caffrey, President Clinton planned to increase the A GENERAL FOCUSES ON COMMUNITY LEADERS IN THE DRUG ONDCP staff to 150 positions. The director con- WAR. (1996). The Addiction Letter,4,no. 4 ,4–5. trols a Special Forfeiture Fund with over $75 mil- HAVEMANN, J. (1973). White House Report/Drug agency lion appropriated in Fiscal Year 1993 to provide reorganization establishes unusual management added funding for high-priority drug-control group. National Journal,5 (18), 653–659. programs. HOGAN, H. (1989). Drug control at the federal level: ONDCP was responsible for national drug con- Coordination and direction. Washington, DC: Con- trol policies, objectives and priorities, and annual gressional Research Service, the Library of Congress. strategy, and a consolidated budget. ONDCP was Report 87-780 GOV. also required to make recommendations to the OFFICE OF NATIONAL DRUG CONTROL POLICY,EXECUTIVE president regarding changes in the organization, OFFICE OF THE PRESIDENT. Press Release: McCaffrey management, personnel, and budgets of the federal Commneds House on Passage of Colmbia/Andrean departments and agencies engaged in the antidrug Drug Emergency Assistance Package, Urges Senate to effort. Act Swiftly. Washington, D.C.: March, 2000. ONDCP was required to promulgate an annual OFFICE OF NATIONAL DRUG CONTROL POLICY,EXECUTIVE national drug control strategy and to coordinate OFFICE OF THE PRESIDENT. Statement of Director and oversee the implementation of the strategy. Barry R McCaffrey Announcment of Emergency and The director had to consult with and assist state Increased Funding Proposal for Colombia and the and local governments regarding drug-control Andean Region. Washington, D.C.: January, 2000. matters. U.S. CONGRESS,HOUSE,SELECT COMMITTEE ON NARCOT- More recently, the ONDCP has set its agenda, at ICS ABUSE AND CONTROL. (1978). Congressional re- least in part, toward international drug control pol- source guide to the federal effort on narcotics abuse icies. The current director, Gen. Barry McCaffrey, and control,1969–76,Part 1 . A Report of the Select has expended significant effort working with the Committee on Narcotics Abuse and Control. 95th Mexican government to thwart drug trafficking in Congress, 2nd sess. Washington, DC: U.S. Govern- Mexico. According to an article in Insight on the ment Printing Office. News, 70 percent of all the cocaine that enters the U.S. NATIONAL ARCHIVES AND RECORDS ADMINISTRATION, United States comes via Mexico (Dettmer, 1997). OFFICE OF THE FEDERAL REGISTER. The United States 1282 U.S. GOVERNMENT: The Organization of U.S. Drug Policy

Government Manual. Washington, DC: U.S. Govern- The complex drug issue, however, does not fit ment Printing Office. the usual organization of the federal government: RICHARD L. WILLIAMS There is no cabinet department with line authority REVISED BY CHRIS LOPEZ over all drug-program resources; and only a few federal agencies are organized around a single drug-related function (e.g., the Drug Enforcement Agency and the National Institute on Drug Abuse). The Organization of U.S. Drug Policy Most of the drug control agencies and all the de- Reducing drug abuse has been a priority for the partments have various other important roles, so U.S. government since the late 1960s, with contin- they must balance their drug and nondrug respon- uing expansion of management attention and fed- sibilities. eral budgets. In 1969, eight agencies and four cabi- Every step in the policy-determination and - net departments received drug-program funding; implementation process is complex and subject to in 1975, seventeen agencies in seven cabinet de- bureaucratic, political, and technical differences of partments were included; the federal drug control opinion. Two of the most difficult aspects of the program for 1993 involves forty-five agencies and drug problem are (1) seeking agreement on the ex- twelve cabinet departments. In 1969, the total tent and nature of the problem, and (2) attempting budtet for federal drug-abuse programs was $81 to assess the impact of the federal effort on the ever million; for 2000, the budget was approximately changing situation. $17.8 billion. During the past two decades, the federal organization for determining drug policy and implement- WHY IS IT DIFFICULT TO ORGANIZE ing drug programs has expanded to involve a sig- DRUG POLICY? nificant portion of the federal government. The following list of cabinet departments and agencies Drug-policy issues are complex. The organiza- that execute drug policy reflects the breadth of im- tion for drug-policy development must be able to plementation activities. handle the complexity of the drug problem and of the government’s response. NATIONAL DRUG Illegal drugs come from both international and CONTROL AGENCIES domestic sources; they include a wide variety of substances; they involve many different forms of The 1992 National Drug Control Strategy lists transportation, geographical areas, criminal activi- over forty-five agencies and several activities in ties, use patterns, and social effects. All these ele- twelve cabinet departments involved in drug-con- ments are dynamic—constantly adjusting to trol efforts: changes in supply and demand. Drug traffickers ACTION and continuing users immediately react to drug law Agency for International Development enforcement pressures by shifting to areas or tech- Department of Agriculture niques that have less risk. Federal managers and Agricultural Research Service policymakers must recognize the complex changes U.S. Forest Service (and the probable causes) and be capable of ad- Central Intelligence Agency justing the federal effort promptly and effectively. Department of Defense National leadership, including an accepted Department of Education strategy and a process to ensure implementation, is Department of Health and Human Services essential to real progress in eliminating illegal Administration for Children and drugs and their use. The president must have con- Families gressional cooperation in authorizing and funding Alcohol, Drug Abuse, and Mental the strategy. The cabinet departments and agencies Health Administration (in- must be willing participants, with an effective pro- cludes the National Institute of cedure for resolving interdepartmental differences Mental Health, the National In- of opinion. stitute on Drug Abuse, the Na- U.S. GOVERNMENT: The Organization of U.S. Drug Policy 1283

tional Institute on Alcohol Department of Transportation Abuse and Alcoholism, the Of- U.S. Coast Guard fice for Substance Abuse Pre- Federal Aviation Administration vention and the Office for Treat- National Highway Traffic Safety Ad- ment Improvement) ministration Centers for Disease Control Department of the Treasury Food and Drug Administration Bureau of Alcohol, Tobacco, and Health Care Financing Administra- Firearms tion U.S. Customs Service Indian Health Service Federal Law Enforcement Training Department of Housing and Urban Develop- Center ment Financial Crimes Enforcement Net- Department of the Interior work Bureau of Indian Affairs Internal Revenue Service Bureau of Land Management U.S. Secret Service Fish and Wildlife Service U.S. Information Agency National Park Service Department of Veterans Affairs Office of Territorial and Interna- Weed and Seed Program tional Affairs The Judiciary COORDINATING MECHANISM FOR Department of Justice DRUG POLICY Assets Forfeiture Fund U.S. Attorneys In reviewing historical drug-policy coordinating Bureau of Prisons systems since the late 1960s, each system reflects a Criminal Division complex set of considerations. Two elements seem Drug Enforcement Administration to differentiate between the various approaches: Federal Bureau of Investigation Either a drug-policy adviser and supporting drug Immigration and Naturalization Ser- staff is fully integrated into the regular policy pro- vice cesses at the White House, or a high-priority cabi- INTERPOL/U.S. National Central net-level activity or agency is established with its Bureau own special policy process but with less participa- U.S. Marshals Service tion in White House internal staff activity. Office of Justice Programs Each president selects his own White House staff Organized Crime Drug Enforcement and establishes a policy-development process to Task Forces meet his needs. Therefore, any policy-coordinating Support of U.S. Prisoners mechanism that is closely related to a president Tax Division must be expected to change with each new admin- Department of Labor istration. Office of National Drug Control Policy Congress has repeatedly attempted to establish a Counter-Narcotics Technology As- ‘‘drug czar’’ in the Executive Office of the President sessment Center (EOP)—one person to oversee drug policy and to High Intensity Drug Trafficking advise both the president and Congress. Areas Special Forfeiture Fund HISTORY Small Business Administration Department of State A chronological summary of drug-policy coordi- Bureau of International Narcotics nating mechanism is presented here, beginning Matters with 1971—first from the perspective of the Exec- Bureau of Politico/Military Affairs utive Branch, then from the perspective of Con- Diplomatic and Consular Service gress. 1284 U.S. GOVERNMENT: The Organization of U.S. Drug Policy

Executive Drug Policy 1971–1976. On the providing direct management assistance to the demand side, President Richard M. Nixon created drug-related operating agencies, FDMassisted in the Special Action Office for Drug Abuse Preven- implementation of President Nixon’s Reorganiza- tion (SAODAP) in the EOP in June 1971—to lead tion Plan No. 2 of 1973. Also in 1973, Dr. Jaffe was and coordinate all federal drug-abuse prevention succeeded at SAODAP by Dr. Robert Dupont who activities. The first director, Dr. Jerome H. Jaffe, in 1975 became the first director of the newly es- was given the added title of Consultant to the tablished National Institute on Drug Abuse. FDM President for Narcotics and Dangerous Drugs. also assumed oversight of the demand-related drug SAODAP then monitored the annual budget pro- activities as SAODAP was phased out of the EOP. cess and prepared budget analyses of all federal Before terminating in mid-1975, SAODAP pub- drug-abuse programs, by agency and by activity. lished the 1974 and 1975 federal strategies, under Also in 1971, President Nixon called for ‘‘an all the auspices of a relatively inactive Strategy Coun- out global war on the international drug traffic’’ cil. (1973 Federal Strategy, p. 112), and his organiza- In early 1975, President Gerald R. Ford directed tion for policy reflected the international perspec- the White House Domestic Council to review the tive. International efforts were coordinated by the federal drug effort. Vice-President Nelson A. Cabinet Committee on International Narcotics Rockefeller chaired an interagency task force called Control (CCINC), chaired by the secretary of state. the Domestic Council Drug Abuse Task Force, with Established in August 1971, CCINC was responsi- the chief of FDMas study director. The task force, ble for developing a strategy to stop the flow of with advice from community organizations, pre- illegal narcotics into the United States and to coor- pared a comprehensive White Paper on Drug dinate federal efforts to implement that strategy. Abuse. The 1975 white paper recommended as- Domestic drug-law enforcement had a high priority signing responsibility for overall policy guidance to within the normal cabinet-management system. the Strategy Council on Drug Abuse; creating an In January 1972, President Nixon created the EOP Cabinet Committee to coordinate prevention Office of Drug Abuse Law Enforcement (ODALE) and treatment activities; and continuing a small in the Department of Justice and gave the ODALE staff in OMB to assist the Strategy Council and the director, Myles J. Ambrose, the added title of Con- EOP. In April 1976, President Ford announced two sultant to the President for Drug Abuse Law En- new cabinet committees, the Cabinet Committee on forcement. The directors of both SAODAP and Drug Law Enforcement and the Cabinet Commit- ODALE had a policyoversight role in advising the tee on Drug Abuse Prevention ‘‘to ensure the coor- president. dination of all government resources which bear on The 1972 legislation authorizing SAODAP also the problem of drug abuse’’ (1976 Strategy, p. 26). created the Strategy Council on Drug Abuse The cabinet committee structure, supported by the (known as ‘‘The Strategy Council’’) and directed FDMstaff, worked to the satisfaction of President the ‘‘development and promulgation of a compre- Ford but did not satisfy Congress. hensive, coordinated, long-term Federal strategy Congress enacted legislation establishing an Of- for all drug abuse prevention and drug traffic func- fice of Drug Abuse Policy (ODAP) in March 1976, tions conducted, sponsored, or supported by the seeking a single individual in the EOP who had Federal government.’’ The cabinet-level strategy responsibility for the overall drug program. Presi- council, with the directors of SAODAP and ODALE dent Ford did not activate the new agency but as co-chairmen, prepared the 1973 Federal Strat- continued with the three cabinet committees, sup- egy for Prevention of Drug Abuse and Drug Traf- ported by the FDMstaff. ficking, the first explicit strategy document. Executive Drug Policy 1977–1980. In March During 1973, the drug program and drug-policy 1977, President Jimmy Carter revised the drug- organizations underwent major change. The Office policy structure, activating ODAP and abolishing of Management and Budget (OMB) established a the three drug-related cabinet committees. Also, he special management office called Federal Drug revitalized the strategy council, with the director of Management (FDM), which supported OMB’s se- ODAP as executive director, to serve as the govern- nior officials, the CCINC, and the White House mentwide advisory committee for all drug-abuse Domestic Council. Given unusually wide latitude in matters. ODAP worked particularly well with the U.S. GOVERNMENT: The Organization of U.S. Drug Policy 1285

White House staff, partially because Director Peter gotiations, and (3) assisting First Lady Nancy Rea- Bourne was also special assistant to the president gan’s drug-abuse prevention efforts. In addition to for health issues and had an excellent relationship overseeing the efforts of the federal drug agencies, with President Carter and the White House staff. DAPO emphasized the use of all opportunities for ODAP aggressively pursued a wide range of policy the federal government to encourage a wide range and coordination activities, including a major re- of nongovernment antidrug activities. DAPO was view of all federal drug programs. directed by Carlton Turner, a pharmacologist, who The President’s Reorganization Project reviewed was succeeded in 1987 by Dr. Donald Ian Mac- the organization of the Executive Branch and rec- donald, a pediatrician. DAPO published the 1982 ommended abolishing ODAP in mid-1977. Within Federal Strategy and, reflecting the broader policy the EOP, ODAP was an unusual federal agency, direction, published the first ‘‘National’’ Strategy in with a strong presence and authority for a single 1984. issue, somewhat contrary to the normal EOP struc- DAPO continued the coordination meetings with ture. Thus, ODAP was a logical target in efforts to the agency heads (the previous Principals Group, streamline the EOP. Congress disagreed strongly renamed the Oversight Working Group) and assis- with the elimination of ODAP, however. After con- ted in the design and implementation of the Na- gressional hearings and negotiations, the Carter tional Narcotics Border Interdiction System Administration compromised by continuing part of (NNBIS), headed by Vice-President George H. the ODAP staff and all the ODAP functions as part Bush. DPO assisted the Cabinet Council on Legal of the White House Domestic Policy Staff (DPS). Policy and the Cabinet Council on Human Re- In March 1978, six members of ODAP’s staff sources with drug matters until the cabinet councils were transferred to DPS and became the Drug Pol- were replaced by the Domestic Policy Council in icy Office (DPO). DPO continued to perform the April 1985. The Domestic Policy Council Working ODAP functions, including responding to congres- Group on Drug Abuse Policy prepared a major sional interests and reporting directly to Peter presidential drug initiative in 1986, with assistance Bourne. After Bourne departed the White House from DAPO. staff in 1978, the drug staff worked through the During this period, the oversight of drug law director of the DPS. In May 1979, the president enforcement moved away from the White House. affirmed the head of DPO (Lee Dogoloff, the asso- In 1984, Congress had established a federal ciate director for drug policy)—as the individual drug law-enforcement czar to ‘‘facilitate coordina- primarily responsible for the federal government’s tion of U.S. operations and policy on illegal drug drug-abuse prevention and control programs. DPO law enforcement.’’ The attorney general was chair- published the 1979 Federal Strategy and a 1980 man of the new cabinet-level National Drug En- Annual Report. A major policy-coordinating mech- forcement Policy Board (NDEPB) with staff offices anism was the monthly meetings held by DPO with in the Department of Justice. DAPO was charged the heads of the major operating agencies (called with ensuring ‘‘coordination between the NDEPB the Principals Group). DPO also supported another and the health issues associated with drug abuse,’’ policy-coordinating mechanism called the National in addition to supporting the president and the Narcotics Intelligence Consumers Committee, es- White House staff. In January 1987, the NDEPB tablished in April 1978. DPO also initiated efforts published the National and International Drug to increase military support for drug-interdiction Law Enforcement Strategy, which expanded on the activities. During the transition to the Reagan Ad- sections of the 1984 National Strategy involving ministration in early 1981, most of President Car- drug law enforcement and international controls. ter’s DPO staff departed. DAPO continued to provide Executive Office over- Executive Drug Policy 1981–1988. In 1981, sight of the entire drug program. President Ronald W. Reagan’s Office of Policy De- In 1987, President Reagan replaced the NDEPB velopment (OPD) included a Drug Abuse Policy by creating a National Drug Policy Board (NDPB) Office (DAPO) similar in organization and role to to coordinate all drug-abuse policy functions. The the preceding DPO. President Reagan charged director of the White House DAPO was a member DAPO with (1) a full range of policy-development and assisted the NDPB in developing the health- and -coordination activities, (2) international ne- related drug policy. The NDPB published Toward 1286 U.S. GOVERNMENT: The Organization of U.S. Drug Policy a Drug-Free America—The National Drug Strat- criminologist and former New York police commis- egy and Implementation Plans in 1988. sioner, was appointed director of ONDCP and was The White House Conference for a Drug Free also given membership in the cabinet. The fourth America was opened in 1987 with DAPO assis- director, retired Army General Barry R. McCaffrey, tance; it was charged with reviewing a wide range was appointed in 1996. of drug programs, policies, and informational activities—including focusing ‘‘public attention on CONGRESSIONAL DRUG-POLICY the importance of fostering a widespread attitude OVERSIGHT of intolerance for illegal drugs and their use throughout all segments of our society’’ (Executive Various legislative committees and subcommit- Order No. 12595, Section 1(c)). The conference, tees oversee the drug-control activities of the Exec- chaired by Lois Haight Herrington, published a utive Branch departments and agencies. In addition final report in 1988 with 107 wide-ranging recom- to the various standing committees, Congress had mendations, including a ‘‘Cabinet-rank position of special drug-oversight activities, including the Sen- National Drug Director.’’ ate Caucus for International Narcotics Control and In late 1988, Congress again passed drug czar the House Select Committee on Narcotics Abuse legislation, authorizing a new agency named the and Control. Special audits and evaluations by the Office of National Drug Control Policy (ONDCP) in General Accounting Office and support from the the EOP. Congressional Research Service also assisted Con- Executive Drug Policy 1989–1990s. ONDCP gress in its oversight role. began operation in the EOP in early 1989, absorb- The continuing congressional interest in estab- ing the NDPB, and terminating the two existing lishing an effective drug-policy oversight mecha- White House drug activities, DAPO and NNBIS. nism reflected the difficulties of the various com- Although never actually a member of the cabinet, mittees in attempting to address the drug activities the first two cabinet-level directors were given of a single agency within the context of the overall broad responsibilities for developing and guiding a federal effort. The frustration was reflected in the National Drug Control Program, including devel- repeated legislative efforts to establish a drug czar oping an annual strategy and overseeing its imple- in the EOP to oversee federal drug policy and to mentation. The first director, William Bennett, had advise both the president and Congress. been secretary of education in the Reagan adminis- For example, the Senate Committee on Govern- tration; he was succeeded by Bob Martinez, a for- ment Operations had a long-term interest in drug- mer governor of Florida. ONDCP had oversight of program oversight. Senator Charles H. Percy, reorganization, management, budget, and personnel sponding to the plan to abolish ODAP in 1977, allocations of all departments and agencies en- summarized the congressional view. Reiterating the gaged in drugcontrol activities. ONDCP used a complex set of interagency coordinating commit- programmatic needs for a single, high-level coordi- tees under a Supply Reduction Working Group, a nating body with broad statutory authority over Demand Reduction Working Group, and a Re- federal drug-abuse policy and its implementation, search and Development Committee. The director Senator Percy stated: chaired the NSC’s Policy Coordinating Committee My concerns are not limited to the question of for Narcotics which ensured coordination between whether the Federal drug abuse effort can function drug law enforcement and national security activi- effectively under this proposal (to abolish ODAP). ties. The director also provided administrative sup- Indeed, my greatest opposition . . . is that Congres- port to the President’s Drug Advisory Council, sional participation in the formulation and execu- which in turn assisted ONDCP in supporting nation of Federal drug policy will be seriously im- tional drug-control objectives through private paired with the demise of ODAP. . . . Although sector initiatives. ONDCP was also required to es- Congress has jurisdiction over the individual offices tablish realistic and attainable goals for the follow- and agencies, this authority is meaningless without ing two years and the following ten years and to corresponding jurisdiction over those responsible monitor progress toward the goals. Following the for coordinating the line agencies’ programs—the election of President Bill Clinton, Lee Brown, a point where policy differences must be reconciled. U.S. GOVERNMENT: The Organization of U.S. Drug Policy 1287

[Congressional Record, September 30, 1977; develop, review, implement, and enforce govern- S-16071–16072]. ment policy and to direct departments and agencies In the House of Representatives, the Select Com- involved. The explicit power to direct other depart- mittee on Narcotics Abuse and Control, headed by ments and agencies was seen as too strong and in Representative Charles Rangel, played an impor- conflict with the principles of cabinet government. tant role in Congressional oversight of drug pro- President Reagan did not accept the legislation. grams and policy. The select committee was formed In 1984, the Congress and the administration in July 1976 ‘‘to oversee all facets of the Federal agreed to establish a cabinet-level NDEPB with a narcotics effort and coordinate the response of the limited charter to coordinate drug law enforce- seven legislative committees in the House which ment. The legislation designated the attorney gen- have jurisdiction over some aspect of the narcotics eral as chairman and primary adviser to the presi- problem.’’ Without legislative jurisdiction, the se- dent and to Congress—on both national and lect committee was primarily a fact-finding activity international law enforcement. to support the seven standing committees in the In 1987, President Reagan signed Executive Or- House of Representatives. The select committee der 12590, broadened the charter of the attorney also was a focal point for congressional pressure for general and the NDEPB to include the entire fed- a legislatively based federal drug czar. In early eral drug program and named the new activity the 1993, the select committee on Narcotics Abuse and National Drug Policy Board. Control was discontinued. In late 1988, Congress passed new drug czar legislation, creating the Office of National Drug DRUG-POLICY LEGISLATION Control Policy in the EOP, with a cabinet-level director and funding provisions for both operating In 1972, Congress passed legislation authorizing expenses and program activities. President Bush the Special Action Office for Drug Abuse Preven- accepted the new agency and appointed a cabinet- tion, as requested by President Nixon. After level director, but he did not include the first direc- SAODAP expired in 1975, Congress authorized a tor or his successor in his immediate cabinet. replacement drug-policy agency (ODAP), in early Thus, Congress achieved the drug czar objec- 1976, and was critical of President Ford’s decision tives that it pursued for two decades—a cabinet- to not open the new agency. level drug-policy manager with broad oversight of When President Carter decided to activate policy and budgets, responsible both to Congress ODAP in early 1977, Congress applauded the deci- and the president. sion and confirmed the director and deputy director; but ODAP was abolished in early 1978 despite (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- congressional objections, ending their successful icy International Drug Supply Systems; Opioids relationship with ODAP. The resulting executive/ and Opioid Control,History; Prevention Move- congressional negotiations required the Drug Pol- ment; Treatment,History of ) icy Office of the DPS to carry out the functions previously assigned to ODAP and to allow congres- BIBLIOGRAPHY sional access to the drug-policy staff. In late 1979, Congress followed up with legisla- HOGAN, H. (1989). Congressional Research Service, the tion requiring the president to establish a drug- Library of Congress. Drug control at the federal level: abuse policy coordination system and to designate Coordination and direction. Report 87-780 GOV. a single officer to direct the activities (21 USC 1111 U.S. CONGRESS,HOUSE. Select Committee on Narcotics & 1112). A system was established by President Abuse and Control. (1978). Congressional resource Carter (Executive Order 12133, 1979-Drug Policy guide to the federal effort on narcotics abuse and Office) and by President Reagan (Executive Order control,1969–76,Part 1 . A Report of the Select Com- 12368, 1982-Drug Abuse Policy Office). mittee on Narcotics Abuse and Control. 95th Con- In late 1982, Congress enacted a strong drug gress, 2nd sess. Washington, DC: Government Print- czar, in an Office of National and International ing Office. Drug Operations and Policy, with a cabinet-level U.S. CONGRESS,HOUSE. Select Committee on Narcotics director. The director was granted broad powers to Abuse and Control. (1980). Recommendation for con- 1288 U.S. GOVERNMENT AGENCIES

tinued house oversight of drug abuse problems.A Bureau of Narcotics and Dangerous Drugs Report of the Select Committee on Narcotics Abuse (BNDD); and Control. Report No. 96-1380. 96th Congress, Center for Substance Abuse Prevention 2nd sess. Washington, DC: Government Printing Of- (CSAP); fice. Center for Substance Abuse Treatment U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Domestic (CSAT); Council Drug Abuse Task Force. (1975). White paper National Institute on Alcoholism and Alcohol on drug abuse September. 1975. Washington, DC: Abuse (NIAAA); Government Printing Office. National Institute on Drug Abuse (NIDA); U.S. EXECUTIVE OFFICE OF THE PRESIDENT. (1980). Do- Office of Drug Abuse Law Enforcement mestic Policy Staff. Annual report on the federal drug (ODALE); program. 1980. Washington, DC: Government Print- Office of Drug Abuse Policy (ODAP); ing Office. Office of National Drug Control Policy U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Drug Abuse (ONDCP); Policy Office, Office of Policy Development. The Special Action Office for Drug Abuse White House. (1984). 1984 national strategy for pre- Prevention (SAODAP); vention of drug abuse and drug trafficking. Washing- Substance Abuse and Mental Health ton, DC: Government Printing Office. Services Administration (SAMHSA); U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Drug U.S. Customs Service; Abuse Policy. (1978). 1978 annual report. Washing- U.S. Public Health Service Hospitals ton, DC: Government Printing Office. U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- tional Drug Control Policy. (1990). National drug Bureau of Narcotics and Dangerous control strategy. January 1990. Washington, DC: Drugs Presidential Reorganization Plan No. 1 of Government Printing Office. 1968 created the Bureau of Narcotics and Danger- U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- ous Drugs (BNDD) in the U.S. Department of Jus- tional Drug Control Policy. (1992). National drug tice. The new agency combined the drug law en- control strategy. January 1992. Washington, DC: forcement functions of two predecessor Government Printing Office. organizations—the Federal Bureau of Narcotics U.S. EXECUTIVE OFFICE OF THE PRESIDENT. President’s (FBN) in the Department of the Treasury and the Advisory Commission on Narcotic and Drug Abuse. Bureau of Drug Abuse Control in the Food and (1963). Final report. Washington, DC: Government Drug Administration, Department of Health and Printing Office. Human Services. Long-standing conflicts between U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Strategy two Department of the Treasury agencies that Council on Drug Abuse. (1973) Federal strategy for shared drug-enforcement responsibilities—the drug abuse and drug traffic prevention. 1973. Wash- Federal Bureau of Narcotics and the Bureau of Cus- ington, DC: Government Printing Office. toms—led to the decision to move the FBN func- U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Strategy tions into a new agency (BNDD) in a different cabi- Council on Drug Abuse. (1976). Federal strategy. net department (Justice). Drug abuse prevention. 1976. Washington, DC: Gov- ernment Printing Office. MISSION AND EXPERIENCE U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Strategy BNDD’s role was to suppress illicit narcotics Council on Drug Abuse. (1979). Federal strategy for trafficking and to control the diversion of legally drug abuse and drug traffic prevention. 1979. Wash- manufactured drugs. BNDD was responsible for ington, DC: Government Printing Office. working with foreign governments to halt interna- RICHARD L. WILLIAMS tional drug traffic, immobilizing domestic illegal drug-distribution networks, providing a wide range of technical assistance and training to state U.S. GOVERNMENT AGENCIES The and local officers, and preparing drug cases for following articles appear in this section: prosecution. U.S. GOVERNMENT AGENCIES: Bureau of Narcotics and Dangerous Drugs 1289

BNDD emphasized investigations of high-level flicts between special agents from BNDD and Cus- drug trafficking to identify and target major na- toms, added to the public perception of tional and international violators. Director John E. fragmentation and disorder in federal drug law Ingersoll described the success of BNDD as being enforcement. ‘‘able to apprehend scores of illicit drug traffickers In early 1973, another presidential reorganiza- who were previously immune to the feeble efforts tion plan was designed to eliminate the overlap and which law enforcement was formerly able to duplication of effort in drug enforcement. A factual mount.’’ In 1968 and 1969, BNDD contributed to assessment of the BNDD/Customs situation, pro- major international success in stopping heroin traf- vided to the Congress by the chief of OMB’s Federal fic originating in Turkey. Drug Management Division, Walter C. Minnick, The Bureau of Customs continued interdiction reported ‘‘Having attempted formal guidelines, in- of drug smuggling at the borders and ports of entry. formal cooperation and specific Cabinet-level me- Customs special agents investigated drug cases diation, all without success, the President con- based on seizures made by Customs inspectors and cluded in March of 1972 that merging the drug on antismuggling intelligence. Conflict between investigative and intelligence responsibilities of BNDD and Customs continued, with allegations of Customs and BNDD into a single new agency was lack of cooperation and failure to share intelligence the only way to put a permanent end to the prob- with each other. lem.’’ Under Reorganization Plan No. 2 of 1973, The White House and Office of Management and BNDD, ODALE, and ONNI were eliminated; their Budget (OMB) tried to resolve the conflict and, in functions and resources, along with 500 Customs early 1970, President Richard M. Nixon directed special agents (those previously involved in drug BNDD and Customs to work out a set of operating investigations), were consolidated in the new Drug guidelines. After considerable interagency discus- Enforcement Administration (DEA) in the Depart- sion, formal guidelines were prepared to give to ment of Justice. BNDD full jurisdiction over drug-enforcement operations both within the United States and over- (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- seas. Customs was to be limited to border opera- icy) tions. The president approved the guidelines, but the conflicts continued. Neither Congress nor the BIBLIOGRAPHY White House was satisfied. Senator Abraham Ribi- BONAFEDE, D. (1970). Nixon seeks to heal top-level feud coff described the detailed guidelines as ‘‘more between customs, narcotics units. National Journal, reminiscent of a cease-fire agreement between com- 2(15), 750–751. batants than a working agreement between suppos- BONAFEDE, D. (1970). Nixon approves drug guidelines, edly cooperative agencies.’’ gives role to Narcotic Bureau. National Journal, 2(29), 1532–1534. ADDITIONAL DRUG FINLATOR, J. (1973). The drugged nation. New York: ENFORCEMENT COMPLICATIONS Simon & Schuster. ࠻ The ‘‘war against drugs’’ continued to expand. MOORE, M. H. (1978). Reorganization Plan 2 reviewed: In 1972, President Nixon established two new drug Problems in implementing a strategy to reduce the agencies in the Department of Justice—the Office supply of drugs to illicit markets in the United States. of Drug Abuse Law Enforcement (ODALE) and the Public Policy,26 (2), 229–262. Office of National Narcotics Intelligence (ONNI). RACHAL, P. (1982). Federal narcotics enforcement. Bos- ODALE’s operational involvement with state and ton: Auburn House. local law enforcement against local drug dealers U.S. CONGRESS,SENATE, Committee on Government Op- was intended to complement BNDD’s focus on high erations. (1973). Reorganization Plan No. 2 of 1973, level traffickers. ODALE, however, depended on Hearings before the Subcommittee on Reorganization, existing federal agencies for agents and attorneys, Research,and International Organizations . 93rd and BNDD was required to lend over 200 narcotics Congress, 1st sess., Part 1. April 12, 13, and 26, 1973. agents to ODALE. The additional antidrug agen- Washington, DC. cies, combined with sensational reporting of con- RICHARD L. WILLIAMS 1290 U.S. GOVERNMENT AGENCIES: Center for Substance Abuse Prevention (CSAP)

Center for Substance Abuse Prevention 3. Operates a national clearinghouse for publica- (CSAP) This agency was originally established as tions on prevention and treatment and other the Office for Substance Abuse Prevention (OSAP). materials and services, including the operation It was created by the Anti-Drug Abuse Act of 1986 of the Electronic Communication System and for the prevention of alcohol and other drug (AOD) the Regional Alcohol and Drug Awareness Re- problems among U.S. citizens, with special empha- source (RADAR) Network. sis on youth and families living in high-risk envi- 4. Supports the National Training System, which ronments. Dr. Elaine Johnson was appointed as the develops new drug-use prevention materials first director of the office. From 1986 to 1992, and delivers training. OSAP operated as a unit of the Alcohol, Drug 5. Supports field development. Abuse, and Mental Health Administration (AD- 6. Conducts an evaluation strategy consisting of AMHA), one of the eight Public Health Service individual grantee evaluations, contractual agencies within the U.S. Department of Health and program-wide evaluations, and the National Human Services. Evaluation Project. In 1992, Public Law 102–321 reorganized AD- 7. Provides technical assistance for capacity AMHA and renamed it the Substance Abuse and building and promotes collaborations to help Mental Health Services Administration states, communities, and organizations de- (SAMHSA); it also created CSAP to replace OSAP. velop and implement communications, drug- The goal of CSAP is to promote the concepts of use prevention, and early intervention efforts. no use of any illicit drug and no illegal or high-risk 8. Develops and implements public information use of alcohol or other legal drugs. (High-risk alco- and educational media campaigns and other hol use includes drinking and driving; drinking special-outreach and knowledge-transfer pre- while pregnant; drinking while recovering from al- vention programs. coholism and/or when using certain medications; 9. Maintains a national drug-use prevention having more than two drinks a day for men and database to provide information on substance- more than one for women, or to intoxication). abuse prevention programs. These are the principles that guide the preven- 10. Provides technical assistance and materials to tion work of CSAP: small businesses for the development of EM- PLOYEE-ASSISTANCE PROGRAMS. 1. The earlier PREVENTION is started in a person’s 11. Operates the National Volunteer Training life, the more likely it is to succeed. Center for Substance Abuse Prevention. 2. PREVENTION PROGRAMS should be knowledge based and should incorporate state-of-the-art To promote interagency cooperation and facili- findings and practices drawn from scientific re- tate jointly sponsored prevention activities, CSAP’s search and field expertise. staff meets routinely with various federal organiza- 3. Prevention programs should be comprehensive. tions, including the departments of defense, justice, 4. Programs should include both process and out- education, transportation, labor, housing and ur- come evaluations. ban development, the Bureau of Indian Affairs, and 5. The most successful programs are likely to be others. those initiated and conducted at the community CSAP also develops partnerships with the re- level. search community, parent groups, foundations, policymakers, health-care practitioners, state and To utilize these principles and achieve its goals, community leaders, educators, law enforcement of- CSAP performs the following functions: ficials, and others to enhance opportunities for 1. Carries out demonstration projects targeting comprehensive approaches to prevention and early specific groups and individuals in high-risk intervention. environments. 2. Assists communities in developing long-term, (SEE ALSO: Education and Prevention; Parents comprehensive AOD-use prevention programs Movement; Prevention Movement) and early intervention programs. ELAINE JOHNSON U.S. GOVERNMENT AGENCIES: Center for Substance Abuse Treatment (CSAT) 1291

Center for Substance Abuse Treatment administering the Substance Abuse Prevention and (CSAT) The Center for Substance Abuse Treat- Treatment (SAPT) Block Grant program, which ment (CSAT) was established in January 1990 as provides federal support to state substance-abuse the Office for Treatment Improvement (OTI) of the prevention and treatment programs (funded at Alcohol, Drug Abuse, and Mental Health Adminis- $1.13 billion in fiscal year 1993). tration (ADAMHA) in the Department of Health Research has generated a vast body of knowl- and Human Services (DHHS). Dr. Beny J. Primm, edge regarding the nature of chemical dependency a physician who had spent more than twenty years and about what works in the treatment of addiction developing a major treatment program in New and addiction-related primary health and mental- York City, was appointed its first director. Follow- health disorders. From this research, three key ob- ing reorganization of ADAMHA in 1992, the servations formed the basis for CSAT’s initial treat- agency was renamed and is now part of the Sub- ment philosophy. First, addiction is a complex phe- stance Abuse and Mental Health Services Adminis- nomenon; people’s addiction cannot be treated in tration (SAMHSA), which replaced ADAMHA. isolation from addressing their primary health, The congressional mandate of CSAT is to ex- mental health, or socioeconomic deficits. Second, pand the availability of effective treatment and addiction is frequently a chronic, relapsing disor- recovery services for people with drug and alcohol der; the gains made during treatment often are lost problems. One of its goals is to ensure that new following a person’s return to the community. treatment technology is absorbed by the addiction- CSAT therefore tried to foster programs that pro- treatment infrastructure—that is, the system of vided those treated for chemical dependency with a state and local government agencies and public and series of interventions along a sustained con- private treatment programs providing addiction- tinuum. These two observations constituted the ba- treatment services. In carrying out this responsibil- sis for CSAT’s Comprehensive Treatment Model, ity, CSAT collaborates with states, communities, which was a central principle in all of its demon- and treatment providers to upgrade the quality and stration grant programs and technical-assistance effectiveness of treatment and enhance coordina- initiatives. During its first few years of existence, tion among drug-treatment providers, human-ser- CSAT targeted resources to the people it perceived vices, educational and vocational services, the as most adversely affected by extreme socioeco- criminal-justice system, and a variety of related nomic problems and at highest risk for addiction services. CSAT provides financial and technical as- because of exposure to CRIME, abuse, POVERTY, sistance for this purpose to targeted geographic and HOMELESSNESS, and also because of lack of areas and patient populations, with emphasis on access to primary health and mental health care, assistance to minority racial and ethnic groups, social services, and vocational training and educa- ADOLESCENTS,HOMELESS people, WOMEN of tion. For this reason, the early CSAT Comprehen- childbearing age, and people in rural areas. sive Treatment Model demonstration grants fos- CSAT also collaborates with other government tered a wide array of primary interventions geared agencies, such as the National Institute on Drug to addressing each patient’s health and human ser- Abuse (NIDA), the National Institute on Alcohol vice needs, coupled with a readily accessible, inten- Abuse and Alcoholism (NIAAA), the National Insti- sive aftercare component. tute of Mental Health (NIMH), the Center for Sub- At the core of CSAT’s overall approach is, quite stance Abuse Prevention (CSAP), and state and simply, the conviction that treatment works. Treat- local governments to promote the utilization of ef- ment has proved effective in reducing the use of fective means of treatment and to develop treat- illicit drugs and alcohol, improving rates of em- ment standards. In addition, CSAT has interagency ployment, reducing rates of HUMAN IMMUNODEFI- agreements with the Department of Labor and the CIENCY VIRUS (HIV) seroconversion, reducing Department of Education that are designed to im- criminal activity, and reducing overall patient mor- prove the coordination of health and human ser- bidity. vices, education, and vocational training. CSAT In addition to the SAPT Block Grant, CSAT also promotes the mainstreaming of alcohol-, drug- awarded grants for a variety of demonstration and abuse, and mental-health treatment into the pri- service programs: The treatment-capacity expan- mary health care system, and it is responsible for sion program provided resources to the states to 1292 U.S. GOVERNMENT AGENCIES: The National Institute on Alcohol Abuse and Alcoholism expand capacity in areas of demonstrated shortage; The National Institute on Alcohol Abuse Target Cities assists metropolitan areas with partic- and Alcoholism The National Institute on Al- ularly high-risk populations in providing treatment cohol Abuse and Alcoholism (NIAAA) is the princi- services and in developing systems to coordinate pal Federal agency for research on the causes, con- and improve the infrastructure of the programs. sequences, treatment, and prevention, of alcohol- Critical Populations is a demonstration project for related problems. NIAAA supports studies both bi- treatment program enhancement aimed at particu- ological and behavioral research; research training larly at-risk groups—ADOLESCENTS; racial and and health professions development programs; and ethnic minorities; residents of public housing; research on alcohol-related public policies. The women and their infants and children; rural popu- NIAAA budget for Fiscal Year 2000 is $293 million. lations; drug and alcohol abusers who are homeless; patients with HIV or AIDS. Criminal justice- related programs include drug-abuse treatment ORGANIZATION programs in PRISONS AND JAILS; diversion to treat- NIAAA is one of 18 research institutes of the ment; special services for probation or parole cli- prestigious National Institutes of Health (NIH), a ents; screening, testing, referral, and treatment ser- component of the U.S. Department of Health and vices for HIV/AIDS, TB, and other communicable Human Services. Three principal staff offices and diseases; literacy, education, job training, and job four Divisions manage and coordinate NIAAA ac- placement services; and case management and tivities: Office of Collaborative Research Activi- DRUG TESTING. CSAT also supported demonstra- ties-manages activities with other NIH Institutes, tion treatment campus programs; several programs government agencies, and other organizations in- aimed specifically at WOMEN and their infants and terested in alcohol-related problems and the Insti- children; AIDS outreach for substance abusers; tute’s international activities and science education linkage of primary care and substance abuse model programs; Office of Policy, Legislation, and programs; state systems development programs; PublicLiaison monitors alcohol-related legislative developments and proposals; provides science- professional training and education; and collabo- based recommendations for changes in public poli- rative efforts with other federal agencies. cies; and supports programs aimed at bridging the After Dr. Primm’s return to New York in 1992 gap between research and practice; Office of Plan- and following Mr. David Mactas’s appointment to ning and Resource Management provides finan- head the agency in 1994, and as part of the Clinton cial, grants, contracts, and other administrative administration’s effort to reinvent government (re- support for Institute programs and activities; Divi- define and refine its functions), CSAT’s demonstra- sion of BasicResearch manages the Institute’s tion grant program emphasis shifted from improve- biological research grants portfolio in areas such as ment of services for the populations in greatest neurosciences, genetics, and molecular biology. Di- need to the development of knowledge about the vision of Clinical and Prevention Research sup- effectiveness of treatment for different subgroups ports studies aimed at developing practical and ef- of the drug-using population. fective ways to prevent and treat alcohol use Information regarding CSAT’s current pro- problems, including new medications development; grams and technical initiatives is available from the interventions with high-risk populations s; and be- CSAT Public Affairs Office, Center for Substance havioral therapies; Division of Intramural Clini- Abuse Treatment, Substance Abuse and Mental cal and Biological Research manages the NIAAA Health Services Administration, 5600 Fishers intramural research program. Lane, Rockville, MD 20857. MAJOR PROGRAMS AND ACTIVITIES (SEE ALSO: Ethnic Issues and Cultural Relevance in NIAAA supports research principally through Treatment; Treatment Types; Vulnerability As extramural grants awarded to scientists at leading Cause of Substance Abuse) U.S. research institutions and through research BENY J. PRIMM conducted by NIAAA’s own intramural staff scien- U.S. GOVERNMENT AGENCIES: The National Institute on Alcohol Abuse and Alcoholism 1293

U.S. Department of Health and Human Services adjunct to psychosocial treatment for alcoholism since 1949 was developed from neuroscience re- National Institutes of Health search. NIAAA anticipates that this number will increase over the next several years as ﬁndings from

National Institute on Alcohol Abuse neuroscience and from genetics point to promising and Alcoholism targets for pharmacological intervention. (NIAAA) Prevention. NIAAA prevention research is aimed at developing effective measures to reduce alcohol- Policy, Legislation, Collaborative Planning and Scientific Affairs Research and Resource related problems, including studies of alcohol-re- Public Liaison Activities Management lated intentional and unintentional injury, alcohol- related violence, alcohol in the workplace; drinking

Clinical and Biometrical and Intramural Clinical and driving deterrence, and the relationship be- Basic Prevention Epidemiological and Biological Research Research Research Research tween alcohol availability and alcohol-related problems. New methodologies permit prevention researchers to target high-risk neighborhoods within larger cities. tists. Findings from these research areas are made Treatment. NIAAA continues to emphasize re- available and accessible through a wide variety of search to improve treatment of alcohol abuse and research dissemination activities. alcoholism and supports a range of treatment or Extramural Research. Genetics. NIAAA sup- clinical studies including clinical trials of treatment ports research aimed at discovering the genes that therapies, patient-treatment matching studies, and predispose individuals to alcoholism and the envi- behavioral/pharmacological treatment ap- ronmental factors that influence its development. proaches. Areas of genetics research include: twin studies to Epidemiology. Alcohol epidemiology provides define precisely what is being inherited; genetic the foundation for monitoring the health of the linkage and association studies to identify the genes population, developing and evaluating prevention for alcoholism and their precise number, identity, and treatment services for alcohol problems, and and modes of action; genetic analysis of alcohol- establishing alcohol-related social policies. NIAAA- related behavior in animals, the genes that influ- supported epidemiology research examines the ence these behaviors, and studies to determine the context, volume, and specific drinking patterns that contributions of the environment and genetics to an lead to particular alcohol-related problems as well individual’s susceptibility for developing alcohol- as the impact of age, gender, race/ethnicity, and related medical disorders such as liver cirrhosis, other sociodemographic factors; genetic, environ- pancreatitis, and fetal alcohol syndrome. mental, and other factors which influence injury or Alcohol and the Brain. Many of the behaviors disease occurrence. associated with alcohol use problems are the result Intramural Research. Scientists in the of alcohol’s effects in the brain. NIAAA research is NIAAA Intramural Research Program (IRP) focus designed to learn how these effects influence the on research opportunities that allow intensive, development of alcohol abuse and alcoholism. Mo- long-term commitment as well as the flexibility to lecular biology and genetic techniques, including adjust research priorities in response to new find- the use of transgenic animals, are becoming an ings. Because clinical and laboratory studies occur integral part of this research. In addition, noninva- side by side, new findings from basic research may sive, functional imaging techniques are used in ani- be transferred readily for appropriate testing and mal and human studies to identify neural circuits application, and clinical hypotheses may, in turn, influenced by alcohol. be posited to lab scientists. Areas of study include Medications Development. NIAAA is strongly identification and assessment of genetic and envi- committed to developing medications to diminish ronmental risk factors for the development of alco- the craving for alcohol, reduce risk of relapse, and holism; the effects of alcohol on the central nervous safely detoxify dependent individuals undergoing system, including how alcohol modifies brain activ- treatment. Naltrexone, an opioid antagonist, the ity and behavior; metabolic and biochemical effects first medication approved as a safe and effective of alcohol on various organs and systems of the 1294 U.S. GOVERNMENT AGENCIES: National Institute on Drug Abuse (NIDA) body; noninvasive imaging of the brain structure quences of nicotine as well as on the medical conse- and activity related to alcohol use development of quences of all illicit drugs. Given that drug abuse is animal models of alcoholism; and the diagnosis, the greatest vector for the spread of HIV, a signifi- prevention, and treatment of alcoholism and asso- cant portion of NIDA’s research investment is spent ciated disorders. NIAAA utilizes a combination of on researching effective prevention and treatment clinical and basic research facilities, which enables strategies to combat HIV/AIDS and other infec- a coordinated interaction between basic research tious diseases. NIDA’s comprehensive research findings and clinical applications in pursuit of these portfolio includes studies on the causes and conse- goals. An 11-bed inpatient ward and a large outpa- quences, the prevention and treatment, and the bi- tient program are located in the NIH Clinical Cen- ological, social, behavioral, and neuroscientific ter in Bethesda, Maryland. bases of drug abuse and addiction. NIDA is also charged with the development of medications to RESEARCH DISSEMINATION treat drug addiction. Additionally, NIDA supports research training and career development, science NIAAA shares relevant findings from alcohol re- and public education, and research dissemination. search with health care practitioners, policy makers NIDA is the largest institution devoted to drug- and others involved in managing alcohol-related abuse research in the world, supporting almost 85 programs, and the general public through publica- percent of all drug-abuse research through grants tions in scientific and clinical journals, general and to scientists, primarily at major research facilities specialized brochures, and pamphlets, manuals in the United States, abroad, and at NIDA’s own clinical bulletins. Research findings are also shared Intramural Research Program (IRP). with the alcohol and general health care communities through three online database services sup- HISTORY ported by the institute: Quick Facts, an epidemiological data base; ETOH, an alcohol-related Drug-abuse research and treatment have been a bibliographic reference database; and the NIAAA concern of the U.S. Public Health Service since the clinical trials database. early 1930s. The Public Health Service Hospitals at Publications, reports, and database services are Lexington, Kentucky, and at Fort Worth, Texas, accessible online at http://www.niaaa.nih.gov. were established in 1929—and the research laboratories were established at Lexington in 1935. ENOCH GORDIS, M.D. NIDA was formally established in 1974 as one of three research institutes within the Alcohol, Drug Abuse, and Mental Health Administration (AD- National Institute on Drug Abuse (NIDA) AMHA), a Public Health Service agency within the The National Institute on Drug Abuse is the world’s Department of Health and Human Services. premier research institute supporting research on NIDA’s mandate was to collect information on the the health aspects of drug abuse and addiction. incidence, prevalence, and consequences of drug NIDA’s vast portfolio supports research on all abuse, to improve the understanding of drugs of drugs of abuse from opiates and cocaine to new and abuse and their effects on individuals, and to ex- emerging drugs such as methamphetamine and ec- pand the ability to prevent and treat drug abuse. stasy. In addition to research on illegal drugs, NIDA Through scientific research, NIDA has built a base supports an extensive research portfolio to combat of information on how drugs affect us—what they what may be the nation’s most critical and costly do to our bodies; to our behavior, thoughts, and public health problem—tobacco use. NIDA’s nic- emotions; to our relationships; and to our society. otine research continues to increase our under- This understanding of the biological, social, behav- standing of the social, economic, cultural and bio- ioral and environmental influences that place indi- logical factors that influence smoking initiation and viduals at risk for drug abuse is of great importance vulnerability to nicotine addiction, and continues to prevention and treatment practitioners, to edu- to bring the nation the most effective prevention cators, and to policymakers. and treatment approaches available. Additionally, In October 1992, the drug, alcohol, and mental- NIDA supports research on the health conse- health activities within the Department of Health U.S. GOVERNMENT AGENCIES: Office of Drug Abuse Law Enforcement (ODALE) 1295 and Human Services (NIDA, along with the Na- and public education program to rapidly provide tional Institute on Alcohol Abuse and Alcoholism research-based information to scientists, practi- and National Institute on Mental Health) were tioners, policy makers, and the general public. transferred from ADAMHA to the National Insti- NIDA staff works closely with local community- tutes of Health. based networks to hold town meetings at various locations across the country, as well as other major FUNCTIONS conferences to ensure that the latest scientific information is disseminated to those working to pre- To improve the ability to prevent drug abuse, vent and treat drug abuse and addiction. NIDA NIDA is concentrating on the variety of biological, also develops written and electronic materials for behavioral, social, and environmental factors involved in vulnerability to drug abuse. This infor- researchers, prevention practitioners, treatment mation enables NIDA to improve both prevention practitioners, young people, parents, policy-mak- and treatment approaches—which are key to over- ers, and others. Additionally, NIDA has a Science coming the demand for drugs—and to inform ef- Education Program, which develops materials for fective U.S. demand-reduction policies. K-12 students and teachers, as well as the general Drug addiction is a chronic, relapsing disorder, public, and funds grants with educators and scien- but research has shown that treatment can be an tists for the development of programs, materials effective tool in helping some to break the addiction and museum exhibits. Through NIDA’s research cycle. Successful treatment offers the best means dissemination programs, science-based informa- for overcoming a life cycle revolving around drug- tion can then be used to educate, prevent, treat, seeking behaviors and also reduces the spread of and rehabilitate. AIDS and other infectious diseases among drug abusers. Accordingly, NIDA is researching ways to CONCLUSION improve the effectiveness of treatment and working to increase retention rates and reduce relapse rates. NIDA conducts and supports RESEARCH that has Through an understanding of the effects of drugs as its underlying principles the goals of eliminating on the brain, NIDA is developing more effective drug abuse, treating those whom prevention fails, treatments-including medications-for specific increasing retention and decreasing relapse, and drugs of abuse, such as COCAINE and HEROIN, and improving the health and well-being of all Ameri- for the toxic effects on the BRAIN and other organs cans, their families, their communities, and the na- that drugs of abuse produce. NIDA has engaged in tion. a major effort to improve research on, and its appli- NIDA collaborates with other research institutes, cation to, services for drug-abusing pregnant and and with other agencies and departments of the postpartum women. NIDA also seeks to develop U.S. government. For more information visit the strategies to prevent or ameliorate the conse- NIDA website at www.nida.nih.gov. quences of drugs of abuse on the children of drug- RICHARD A. MILLSTEIN abusing parents. REVISED BY ALAN.I.LESHNER To support this array of research programs, the research community needs an adequate supply of scientists with up-to-date skills and knowledge. Accordingly, NIDA sponsors drug-abuse research Office of Drug Abuse Law Enforcement programs in the biomedical and behavioral sci- (ODALE) Located within the U.S. Department ences. These programs include support of pre- and of Justice, the Office of Drug Abuse Law Enforce- post-doctoral training in medical schools, universi- ment (ODALE) was established by President Rich- ties, and other institutions of higher education in ard M. Nixon with Executive Order 11641 in Janu- basic, clinical, behavioral, and epidemiological re- ary 1972. Myles J. Ambrose was appointed director search, to assure the steady supply of trained sci- of ODALE and held two other concurrent titles: entists. A final important function of NIDA is to special consultant to the president for drug abuse make research findings available to the widest au- law enforcement and special assistant attorney dience possible. NIDA has an extensive outreach general. 1296 U.S. GOVERNMENT AGENCIES: Office of Drug Abuse Policy

FEDERAL, STATE, AND U.S. CONGRESS,SENATE, Committee on Government Op- LOCAL TEAMWORK erations. (1973). Reorganization Plan No. 2 of 1973, Establishing a Drug Enforcement Administration in Complementing federal efforts directed at the Department of Justice. Report of the Subcommittee ‘‘high-level drug traffickers,’’ ODALE was charged on Reorganization,Research,and International Or- with attacking the heroin-distribution system at the street level to reduce the drug’s availability there. ganizations, 93rd Congress. 1st sess., Report No. 93– Patterned after the justice department’s Organized 469. Washington, DC. Crime Strike Forces, the ODALE program included U.S. GENERAL ACCOUNTING OFFICE. (1975). Federal drug task forces of federal, state, and local law-enforce- enforcement: Strong guidance needed. Report No. ment officers and attorneys. The full use of federal, GGD-76-32. Washington, DC. state, and local narcotics laws, the availability of RICHARD L. WILLIAMS assigned attorneys, and the use of the investigative grand jury made possible a wide range of approaches in pursuing violators. Office of Drug Abuse Policy In March ODALE established task forces in thirty-four 1976, Congress authorized the creation of the Of- cities in 1972 and encouraged citizens to ‘‘report fice of Drug Abuse Policy (ODAP) in the Executive information regarding alleged narcotics law viola- Office of the President, with an annual budget of tors in strict confidence.’’ The federal government $1.2 million. President Jimmy Carter opened the paid for task force equipment and operational ex- office in March 1977 and appointed Dr. Peter G. penses, including payments for a portion of the Bourne as director. salaries and overtime of state and local officers. The director of ODAP was given wide responsi- ODALE was credited with more than 8,000 narcot- bilities in assisting the president with all federal ics arrests with a conviction rate of more than 90 drug-abuse matters, including providing ‘‘policy percent during its 17 months of operation. Never- direction and coordination among the law enforce- theless, ODALE agents were widely criticized for ment, international and treatment/prevention pro- conducting several drug raids involving unautho- grams to assure a cohesive and effective strategy rized forcible entries into private homes and fail- that both responds to immediate issues and pro- ures in identifying themselves as law officers during vides a framework for longer-term resolution of drug raids. problems.’’ The statutory authority included setting objectives, establishing priorities, coordinat- REORGANIZATION ing performance, and recommending changes in ODALE was abolished on July 1, 1973, by Presi- organization. dential Reorganization Plan No. 2 of 1973 and During the first year of operation, ODAP con- ‘‘those Federal operations designed to attack nar- ducted several international missions and worked cotics traffic at the street level in cooperation with closely with United Nations narcotics organiza- local authorities’’ were transferred to the newly es- tions. In coordinating federal drug activities, ODAP tablished Drug Enforcement Administration relied on biweekly discussion meetings with the (DEA). The ODALE program was redesignated as heads of the principal drug agencies. Policy deter- DEA’s State and Local Task Force program. mination was executed through cooperative inter- ODALE’s Deputy Director John R. Bartels, Jr., be- agency study efforts. ODAP completed six compre- came the first administrator of the DEA. hensive interagency policy reviews: border management, drug law enforcement, international (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- narcotics control, narcotics intelligence, demand icy) reduction, and drug abuse in the armed forces. The ODAP staff coordinated preparation of President Carter’s August 1977 Message to the BIBLIOGRAPHY Congress on Drug Abuse and initiated the planning RACHAL, P. (1982). Federal narcotics enforcement. Bos- for a comprehensive federal strategy to be pub- ton: Auburn House. lished by the revitalized Strategy Council. U.S. GOVERNMENT AGENCIES: Office of National Drug Control Policy 1297

REORGANIZATION (state and local affairs), all appointed by the president with the advice and consent of the Senate. After one year of successful operation, ODAP The director has a broad mandate for establish- was abolished by Reorganization Plan No. 1 of ing policies, objectives, and priorities for the Na- 1977, effective March 31, 1978. Six ODAP staff tional Drug Control Program. Serving as the presi- members were transferred to a special drug-policy dent’s drug-control adviser and as a principal unit (Drug Policy Office) within the White House adviser to the National Security Council (NSC), the Domestic Policy Staff. The drug-policy staff con- director has extraordinary management tools avail- tinued to report to Dr. Bourne who became special able to influence the national drug-control efforts. assistant to the president for health issues. ONDCP is required to produce an annual Na- tional Drug Control Strategy for the president and (SEE ALSO: Anslinger,Harry J. and U.S. Drug Pol- Congress and is responsible for overseeing its im- icy) plementation by the federal departments and agencies. Included is an annual consolidated National BIBLIOGRAPHY Drug Control Program budget and the director’s certification that the budget is adequate to imple- HAVEMANN, J. (1978). Carter’s reorganization plans— ment the objectives of the strategy. In addition to Scrambling for turf. National Journal,10 (20), 788– the strategy and program oversight, the director 794. has two other legislated management tools—(1) U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Drug approval of reprogramming of each agency’s drug Abuse Policy. (1978). 1978 Annual Report. Washing- funds and (2) formal notification to the involved ton, DC: Government Printing Office. agency and the president when a drug-program RICHARD L. WILLIAMS agency’s policy does not comply with the strategy. The director also recommends changes in organization, management, and budgets of departments and agencies engaged in the drug effort, including Office of National Drug Control Policy personnel allocations. The Office of National Drug Control Policy (ON- Reflecting congressional desire to participate in DCP) was established on January 29, 1989, by drug policy, the director must represent the admin- Public Law 100–690 (21 USC 1504) as the drug- istration’s drug policies and proposals before Con- coordination agency for the Executive Office of the gress. Additionally, the authorizing legislation spe- President (EOP) under President George H. Bush. cifically allows Congress access to ‘‘information, ONDCP is responsible for coordinating federal ef- documents, and studies in the possession of, or forts to control illegal drug abuse. It is the product conducted by or at the direction of the Director’’ of almost two decades of congressional efforts to and to personnel of the office. mandate a so-called drug czar—the law providing The first director of ONDCP was William J. Ben- for cabinet-level status and congressional involve- nett, 1989–1990, previously the secretary of edu- ment in drug-control policy. Its initial five-year cation during the administration of President Ron- authorization, which expired November 17, 1993, ald W. Reagan. Director Bennett had the difficult was extended. job of starting the new agency from scratch and ONDCP oversees international and domestic an- developing a new national drug-control strategy tidrug functions of all executive agencies and en- within the first year of operation. Reagan’s succes- sures that such functions sustain and complement sor, President Bush, declined to include the cabi- the government’s overall antidrug efforts. net-level ONDCP director in his immediate cabinet, bringing congressional criticism. Bob Martinez (the THE DIRECTOR former governor of Florida) was the next director, 1991–1992. The third director, Lee P. Brown, a ONDCP is led by a director (commonly referred criminologist and a former New York City police to as the drug czar) with cabinet-level rank (Execu- commissioner, was appointed by President Bill tive Level 1), two deputies (supply reduction and Clinton in 1993 and was given cabinet status. The demand reduction), and one associate director fourth director, retired Army General Barry R. Mc- 1298 U.S. GOVERNMENT AGENCIES: Office of National Drug Control Policy

Caffrey, a decorated combat veteran in Vietnam, ONDCP’s broad coordination authority over was also appointed by President Clinton, in 1996. budgets and program activity also presents extraor- McCaffrey is expected to be replaced with a change dinary opportunities for conflict with the existing in administrations after the November 2000 Presi- line authority in the departments and agencies. Si- dential election. multaneously, ONDCP receives congressional and press criticism regarding lack of influence over the ORGANIZATION AND AUTHORITY operating activities. Initially, ONDCP had approximately 127 staff POLICY DEVELOPMENT positions and 40 additional members detailed from AND COORDINATION other federal agencies. ONDCP’s Fiscal Year (FY) 1992 appropriation of $105 million included $86 The continued success of the complex drug-pol- million to be transferred to support the High Inten- icy system depends on a continuing high priority sity Drug Trafficking Areas (HIDTA). The HIDTA for the drug programs, preventing bureaucratic funding provides $50 million for federal law-en- turf battles, and seeking widespread understanding forcement agencies and $36 million for state and and endorsement of the goals and objectives of the local drug-control activities. President Clinton national program. An essential element in commu- drastically reduced the size of the ONDCP staff nicating is a public document that explains the soon after his election, from 146 to 25. With the strategy, goals, and responsibilities—including a appointment of General Barry R. McCaffrey Presi- dynamic process of evaluating results and updating dent Clinton intended to bring the number of staff the strategy. back up to its original capacity. Additionally, Presi- The annual National Drug Control Strategy, dent Clinton wished to appropriate money from the with accompanying Budget Summary (the Febru- Department of Defense. ary 1999 strategy was the most recent in the series) The director is responsible for a Special Forfei- contains a description of the drug-abuse situation, ture Fund, funded by the department of Justice an assessment of progress, and national priorities— Assets Forfeiture Fund, ‘‘to supplement program with two-year and ten-year objectives and a federal resources used to fight the war on drugs.’’ For FY budget ‘‘cross-cut’’ and analysis. ONDCP has 1992, this fund included over $50 million for brought together a complex set of drug-control transfer to federal program agencies. program functions and budgets in an understand- Additionally, ONDCP reviews and recommends able way; by function in the strategy and by agency funding priorities for the annual budget requests in the budget summary. Under Lee P. Brown the for over fifty federal agencies and accounts in- office produced an interim strategy for 1993 and a volved in the drug program (more than $12 billion fully developed strategy in February 1994. McCaf- in FY 1993). frey’s 1999 strategy, similar to previous years’ ver- ONDCP’s authority to provide direction to di- sions, concentrated on five areas: (1) increasing verse federal departments and agencies is based on anti-drug education aimed at children; a program-management structure known as the (2) decreasing the number of addicted people by National Drug Control Program. The ONDCP pro- closing the ‘‘treatment gap’’; (3) breaking the cycle gram and budget authority coexists with the line of drugs and crime; (4) securing the nation’s bor- authority of the cabinet departments and with the ders from drugs; and (5) reducing the overall drug president’s annual budget process (directed by the supply. The goal of this strategy is to shrink the use Office of Management and Budget). The structure and availability of illegal drugs by 25 percent by for the parallel drug-control system is created by 2002 and by 50 percent by 2007. Additionally, the designating National Drug Control Program agen- plan assures a 30 percent reduction in drug-related cies, defined as ‘‘any department or agency and all crimes by 2007, as well as a 25 percent reduction in dedicated units thereof, with responsibilities under health- and social-related drugs costs. (Advocates, the National Drug Control Strategy.’’ The desig- 1999). nated federal departments and agencies have spe- The National Drug Control Strategy acknowl- cial program and budget responsibilities to the di- edges that no single tactic will solve the drug prob- rector of ONDCP. lem. Therefore, the annual strategies call for im- U.S. GOVERNMENT AGENCIES: Office of National Drug Control Policy 1299 proved and expanded treatment, prevention and activities. Four metropolitan HIDTAs have been education; increased international cooperation; ag- designated: New York City, Miami, Houston, and gressive law enforcement and interdiction; ex- Los Angeles. panded use of the military; expanded drug intelli- ONDCP Demand Reduction Working Group. gence; and more research. Chaired by the ONDCP deputy director for demand reduction, the working group coordinates policies, ORGANIZATION FOR COORDINATION objectives, and outreach activities for treatment, education and prevention, workplace, and interna- ONDCP has established a drug-control manage- tional demand reduction. ment agenda, including federal coordinating mech- Research and Development Committee. anisms and senior-level management committees Chaired by the director of ONDCP, the committee and working groups. The organization of ONDCP provides policy guidance for R&D activities of all includes staff for supply reduction, demand reduc- federal drug control agencies, including the follow- tion, and state and local affairs. ONDCP working ing R&D working committees— groups and committees coordinate the implemen- The Data Committee. Improves the relevance, tation of the policies, objectives, and priorities es- timeliness, and usefulness of drug-related data col- tablished in the National Drug Control Strategy. lection, research studies, and evaluations of both The federal drug-control agencies and depart- demand-related and supply-related activities. ments are represented on the various working The Medical Research Committee. Coordinates pol- groups and committees, along with ONDCP staff. icy and general objectives on medical research by The organizational structure includes the following federal drug-control agencies and promotes the dis- coordinating mechanism: semination of research findings. ONDCP Supply Reduction Working Group. The ONDCP Science and Technology Committee. Chaired by the ONDCP deputy director for supply Chaired by the ONDCP chief scientist, the commit- reduction, the working group includes three com- tee is responsible for oversight of counterdrug re- mittees: search and development throughout the federal The Border Interdiction Committee. Coordinates government. strategies and operations aimed at interdicting drugs between source and transit countries and at RELATED POLICY ACTIVITIES U.S. borders. The ONDCP may become more internationally-oriented in the future as the policy of The Counter-Narcotics Technology Assessment source control continues to dominate US policy. Center, established by Public Law 101–509 in For example, McCaffrey continues to work with the 1991, provides oversight of the federal govern- Mexican government to control drug trafficking at ment’s counternarcotics research and development the U.S. southern border (Dettmer, 1997). Also, activities. ONDCP’s chief scientist is responsible for there has been a recent push by McCaffrey, with defining scientific and technological needs for fed- support from President Clinton, to provide more eral, state, and local law-enforcement agencies, and than a billion dollars in aid to Colombia for drug for determining feasibility and priorities. The chief interdiction endeavors (ONDCP, Statement, scientist also coordinates the technology initiatives 2000). According to a March 29, 2000 press release of federal civilian and military departments, in- from the ONDCP that aid package was passed by cluding research on substance-abuse addiction and the House of Representatives (ONDCP, Press Re- rehabilitation. lease, 2000). ONDCP works with the NSC, chairing the Policy The Public Land Drug Control Committee. Coordinating Committee for Narcotics to oversee Coordinates federal state, and local drug control coordination among agencies with law-enforce- programs (primarily marijuana eradication efforts) ment and national-security responsibilities. The di- on federal lands. rector also participates in meetings of the Domestic Southwest Border and Metropolitan HIDTA Com- Policy council, which reviews the annual drug con- mittees. Coordinates drug law enforcement activi- trol strategy before it goes to the president. ties in designated areas, including federal, state, ONDCP’s state and local affairs staff sought and local enforcement task forces and intelligence wide public involvement in developing and imple- 1300 U.S. GOVERNMENT AGENCIES: Special Action Office for Drug Abuse Prevention (SAODAP)

menting drug policy at all levels of government. REPORT ON MCCAFFREY DEPARTURE ADDS GRIST TO D.C RU- Several national conferences on state and local MOR MILL. (1999). Alcoholism & Drug Abuse Weekly, drug policy were sponsored by ONDCP during 13,issue 8 , 5&ndas;6. 1990 and 1991 to highlight successful state and REPORT TO QUESTION STRENGTH OF ONDCP AFTER local programs, seek input to the national strategy, MCCAFFREY. (2000). Alcoholism & Drug Abuse and inform participants of funding and initiatives Weekly,12,issue 27 ,5. available to them. ONDCP staff coordinated with U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- both the White House Office of National Service tional Drug Control Policy. (1989). National drug and the president’s Drug Advisory Council in en- control strategy,September 1989 . Washington, DC: couraging private-sector and state-and-local initia- Government Printing Office. tives for drug prevention and control. U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- ONDCP also provides administrative support to tional Drug Control Policy. (1990). National drug the president’s Drug Advisory Council. With thirty- control strategy,January 1990 . Washington, DC: two private citizens as members, the Drug Advisory Government Printing Office. Council focuses on private-sector initiatives to sup- U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- port national drug-control objectives, and it assists tional Drug Control Policy. (1991). National drug the ONDCP. The advisory council is financed by control strategy,February 1991 . Washington, DC: private gifts. Government Printing Office. U.S. EXECUTIVE OFFICE OF THE PRESIDENT. Office of Na- tional Drug Control Policy. (1992). National drug (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- icy; Opioids and Opioid Control,History of ) control strategy,January 1992 . Washington, DC: Government Printing Office.

BIBLIOGRAPHY RICHARD L. WILLIAMS REVISED BY CHRIS LOPEZ ADVOCATES SAY ONDCP STRATEGY OFFERS FEW SOLU- TIONS. (1999). Alcoholism & Drug Abuse Weekly,11, issue 7,3–4. Special Action Office for Drug Abuse ANTI-DRUG CZAR GEN.MCCAFFREY: MAKE TREATMENT KEY Prevention (SAODAP) The Special Action Of- WEAPON. (1996). American Media News,39,no. 26 , fice for Drug Abuse Prevention (SAODAP) was cre- 27–28. ated by Executive Order of President Richard M. DETTMER,J.&LINEBAUGH, S. (1997). McCaffrey’s Nixon on June 17, 1971, as a response to public no-win war on drugs. Insight on the News,13,no. 7 , concern about drug abuse, particularly heroin ad- 8–12. diction. SAODAP was given legislative authority by A GENERAL FOCUSES ON COMMUNITY LEADERS IN THE DRUG the Drug Abuse Office and Treatment Act on March WAR. (1996). The Addiction Letter,4,no. 4 ,4–5. 21, 1972. The formation of SAODAP represented OFFICE OF NATIONAL DRUG CONTROL POLICY,EXECUTIVE the first attempt to establish a stable focus within OFFICE OF THE PRESIDENT. Press Release: McCaffrey the federal government for the coordination of the Commends House on Passage of Colmbia/Andrean many facets of U.S. drug policy, including law Drug Emergency Assistance Package, Urges Senate to enforcement, border control, control of selected Act Swiftly. Washington, D.C.: March, 2000. medicines, treatment, prevention, education, and OFFICE OF NATIONAL DRUG CONTROL POLICY (ONDCP). research. Statement of Directory Barry R. McCaffrey An- More than twenty agencies, offices, and bureaus nouncement of Emergency and Increased Funding within the U.S. government were responsible for Proposal for Colombia and the Andean Region. activities relating to drug problems. Yet there was (Washington, D.C., 2000). no evident central authority other than the presi- ONDCP MATCH INFORMATION NOW AVAILABLE ONLINE. dent. Congress and the public seemed eager to be (2000). Insight on the News,12,issue 19 ,6. able to hold accountable the head of one agency ONDCP MEDIA CAMPAIGN COULD RECEIVE FUNDING CUT who, unlike the president, could be asked to testify (Offic of National Drug Control Policy). (2000). Alco- before congress—a ‘‘drug czar.’’ Although the term holism & Drug Abuse Weekly,12,issue 31 ,5. ‘‘drug czar’’ was popularly used, and it was expec- U.S. GOVERNMENT AGENCIES: Special Action Office for Drug Abuse Prevention (SAODAP) 1301 ted that the person holding the office would exert but it was not known if these estimates were of power over the various agencies dealing with both drug users or of addicts. law enforcement (supply side) and treatment and In addition to the mandate to coordinate all the prevention (demand side) aspects of the problem, demand side drug-abuse activities of the federal neither the president nor the Congress were entirely bureaucracy so as to reduce overlap and redun- comfortable with delegating such broad authority dancy and to expand treatment capacity, some of to only one individual. the additional tasks of the office included over- The legislation submitted to Congress by the seeing and coordinating the Vietnam drug-abuse White House, which finally emerged from debate, intervention; creating a new federal agency with gave SAODAP unprecedented authority over de- competence to develop national policy; creating the mandside activity—treatment, prevention, educa- data systems by which the effectiveness of national tion, research—wherever these were carried out policy could be evaluated; creating a science base within the federal government. However, its man- so that research might lead to better ways to treat date with respect to drug-control agencies such as and prevent addiction; and developing a formal, the U.S. Customs Bureau, which reported to the written National Strategy for drug-abuse treatment secretary of the treasury, and the Bureau of Narcot- and prevention. ics and Dangerous Drugs, which reported to the Four major policy changes helped the agency attorney general, was limited to coordination. achieve its objectives. The first was made by the SAODAP was also charged with developing a for- president when the Vietnam testing and treatment mal, written, national strategy for drug-abuse pre- program was initiated: Drug use was no longer a vention. To head the new office, President Nixon court martial offense. The second was having the appointed Dr. Jerome H. Jaffe, then a professor of federal government take responsibility for develop- psychiatry at the University of Chicago and direc- ing and funding treatment. The third made tor of the Illinois Drug Abuse Programs. Dr. Jaffe, METHADONE-MAINTENANCE treatment, already be- who had helped the White House develop its re- ing used for 20,000 people, an established and sponse to HEROIN use in VIETNAM, was also acceptable treatment method rather than an exper- appointed special consultant to the president on iment. The fourth had to do with changes that were narcotics and dangerous drugs. made in the thinking, language, and means by A primary goal of SAODAP, stated at the press which treatment was supported. conference that announced the new office, was to A central effort for SAODAP was the expansion make treatment so available that no addicts could of treatment capacity, increasing not only the say they committed crimes because they could not number of programs, but also their actual capacity get treatment. Although the Bureau of Narcotics and geographic distribution. In addition, recipi- and Dangerous Drugs (BNDD) had estimated that ents of funding for treatment programs became there were about a half million heroin users in the accountable for what they provided, such as the United States, in mid-1971 the true extent of the number of treatment slots and the type of treat- drug-abuse problem was unknown. The esti- ment. While legitimizing methadone-maintenance mating techniques that were developed in the treatment and developing regulations for its use 1970s—the NATIONAL HOUSEHOLD SURVEY ON were highly visible and highly controversial activi- DRUG ABUSE, the DAWN system (or DRUG ABUSE ties, they were only incidental to the overall mis- WARNING NETWORK), and the HIGH SCHOOL SE- sion of making effective treatment central to the NIOR SURVEY—did not yet exist, but the rising rate nation’s response to the drug problem. Within the of heroin-related deaths in several major cities and first 18 months of SAODAP’s efforts, the number the thousands of addicts waiting for treatment be- of communities with federally supported drug- cause there was not enough treatment capacity treatment programs increased from 54 to 214, and gave stark evidence for the growing size of the the number of programs grew to almost 400. More heroin problem. There were drug OVERDOSE (OD) federally supported treatment capacity was devel- deaths among U.S. troops in Vietnam also. Sur- oped within two years than over the previous fifty veys generally indicated widespread drug use years. among U.S. servicemen in Vietnam, with the ex- Some of the other projects SAODAP initiated, tent of the problem estimated at 15 to 30 percent, funded, or grappled with were the Vietnam drug 1302 U.S. GOVERNMENT AGENCIES: Substance Abuse and Mental Health Services Administration intervention and the Vietnam drug intervention later. This discovery forms the basis for much of the follow-up study; the development of confidentiality neuroscience research into understanding the bio- regulations to protect the medical records of people logy of drug dependence. seeking treatment; funding clinical research on new SAODAP was able to change the national re- pharmacological treatments for drug dependence; sponse to illicit drug use by developing an infra- initiating with other agencies projects such as structure for treatment that is largely still in place, TREATMENT ALTERNATIVES TO STREET CRIME one that recognizes the heterogeneity of the drug- (TASC), research centers for clinical and basic re- using population, their need for several different search on drug abuse and addiction, the Career types of treatment, and the need for research on the Teachers program that incorporated drug abuse efficacy of treatment. For a brief period after into medical school curricula, and a National SAODAP’s mandate expired in 1975, drug-abuse Training Center. SAODAP introduced formula or policy was coordinated by a smaller office within block grants that gave money through the NA- the Office of Management and Budget (OMB) un- TIONAL INSTITUTES ON MENTAL HEALTH (NIMH) to der President Gerald R. Ford, and then by the Drug the states for treatment and prevention programs; Abuse Policy Office within the White House under it also introduced management concepts and lan- presidents Jimmy Carter and Ronald W. Reagan. guage into treatment systems. SAODAP played a However, until President George H. Bush estab- major role in improving drug-abuse treatment in lished the Office of National Drug Control Policy the Veterans Administration; establishing labora- (ONDCP), there was no formal agency with sub- tory standards for urine-testing facilities; and ini- stantial authority for coordinating federal drug tiating several of the epidemiological tools that con- policy. tinue to shape policy, such as the National Household Survey of Drug Abuse and the Drug (SEE ALSO: Industry and Workplace,Drug Use in ) Abuse Warning Network (DAWN) system. Many of FAITH K. JAFFE the programs and activities developed with inter- JEROME H. JAFFE agency cooperation were implemented by the agencies involved in the collaboration. Many of the activities are ongoing in the mid-1990s. SAODAP also produced the first written national strategy, Substance Abuse and Mental Health entitled ‘‘Federal Strategy for Drug Abuse and Services Administration (SAMHSA) This Drug Traffic Prevention.’’ Agency, established by Congress on October 1, Since the baseline funding for drug-abuse treat- 1992 (Public Law 102-321), works with States, ment, prevention, and research was so low in 1971, communities and organizations to strengthen the the new resources given to SAODAP for the task Nation’s capacity to provide substance abuse pre- represented a manyfold increase—and in some invention, addiction treatment and mental health stances were the very first resources available for services for people experiencing or at risk for men- the purpose. The same legislation that authorized tal and substance abuse disorders. The newest SAODAP provided for the establishment of the Na- agency of the U.S. Department of Health and Hu- tional Institutes on Drug Abuse (NIDA); in addi- man Services, SAMHSA’s fiscal year 2000 budget is tion, the resources and policies for an invigorated approximately $2.6 billion; it employs a staff of research effort were put into place over the three approximately 550. budgetary cycles that preceded NIDA’s creation. The Agency houses three programmatic Centers: Dr. Robert Dupont, who succeeded Dr. Jaffe as the Center for Substance Abuse Prevention director of SAODAP, became the first director of (CSAP), the Center for Substance Abuse Treatment NIDA. Dr. Peter Bourne and Mr. Lee Dogoloff, both (CSAT), and the Center for Mental Health Services of whom worked at SAODAP during the first two (CMHS). SAMHSA also includes an Office of the years, later became key advisors on drug policy to Administrator, an Office of Applied Studies, and an President Jimmy Carter. Office of Program Services. A noted researcher, Dr. Solomon Snyder, credits Grant portfolios include both block and discre- the SAODAP support he received with enabling tionary grants. Block grants enable States to main- him to discover the opiate RECEPTOR a year or two tain and enhance their substance abuse and mental U.S. GOVERNMENT AGENCIES: Substance Abuse and Mental Health Services Administration 1303 health services. Targeted Capacity Expansion CMHS also supports grant programs to develop grants give communities resources to identify and and apply knowledge about best community-based address emerging substance abuse and mental practices designed to serve adults with serious men- health service needs at their earliest stages. tal illnesses and children with serious emotional SAMHSA’s Knowledge Development and Applica- disturbances. The Center also collects and analyzes tion discretionary grants implement and assess new national mental health services data to help inform community-based prevention and treatment future services decision-making. CMHS’s informa- methods. tion clearinghouse—the Knowledge Exchange Net- The Center for Substance Abuse Prevention work (KEN)—can be reached by toll-free tele- (CSAP) is the Nation’s focal point for the identifi- phone (1-800-789-2647) and on the Internet at cation, promotion, and dissemination of effective www.mentalhealth.org. strategies to prevent drug and alcohol abuse, and While SAMHSA’s Office of the Administrator the use of tobacco. CSAP programs identify pre- and Office of Program Services are primarily ad- vention strategies-such as targeted family and com- ministrative in nature, the Office of Applied Studies munity strengthening-that work best for specific (OAS) has program authority to gather, analyze, populations at risk of substance abuse. Program and disseminate data on substance abuse practices approaches emphasize both cultural relevance and in the United States. OAS directs the annual Na- competence. The Center oversees Federal workplace drug testing programs as well as State tional Household Survey on Drug Abuse,the Drug implementation of the Synar youth tobacco access Abuse Warning Network,and the Drug and Alcohol reduction law. Finally, CSAP supports the National Services Information System, among other studies. Clearinghouse for Alcohol and Drug Information Through these studies, SAMHSA is able to identify (NCADI), the Nation’s largest information source trends in substance abuse and, soon, also in mental on substance abuse research, treatment, and pre- health care. OAS also coordinates evaluation of vention. NCADI’s toll-free number is 1-800-729- models developed through SAMHSA’s knowledge 6686; its Internet address is: www.health.org. development and application programs. The Center for Substance Abuse Treatment New program topics are identified by SAMHSA (CSAT) is enhancing the quality of substance abuse in varying ways. Some are developed by SAMHSA treatment services and working to ensure that ser- leadership and staff; others result from Congressio- vices are available to everyone who need them. It nal mandate. Still other topics grow from Center- supports the identification, evaluation and dissemi- sponsored meetings that highlight empirically vali- nation of science-based, effective treatment ser- dated, intervention models ripe for replication. vices. CSAT administers the State Substance Abuse Some new program directions originate at the State Prevention and Treatment block grant and under- and local levels, some from SAMHSA and Center takes knowledge development, education, and National Advisory Councils, and some from the communications initiatives that promote best prac- research community. tices in substance use/abuse treatment and inter- Programs are bringing new science-based vention. CSAT’s Targeted Capacity Expansion knowledge to community-based prevention, identi- Program–and its specialized program focused on fication and treatment of mental and substance HIV/AIDS services–help communities respond abuse disorders. The results are being measured in rapidly to emerging local drug use trends. improved approaches to addiction treatment, sub- SAMHSA’s Center for Mental Health Services stance abuse prevention and mental health services (CMHS) works to improve the availability and ac- at the federal, state and community levels. Equally cessibility of high-quality care for people with or important, the results are being measured in the at-risk for mental illnesses and their families by improved quality of people’s lives. For further in- creating a nationwide community-based mental health service infrastructure. Its education pro- formation, write to SAMHSA Office of Communi- grams are helping to end the stigma associated with cations, Room 13C05, 5600 Fishers Lane, Rock- these illnesses. While the largest portion of the Cen- ville, MD 20857. ter’s annual budget supports the Community Men- ELAINE JOHNSON tal Health Services Block Grant Program to States, REVISED BY THEODORA FINE 1304 U.S. GOVERNMENT AGENCIES: U.S. Customs Service

U.S. Customs Service The U.S. Customs ing drug-sniffing DOGS, electronic chemical detec- Service (USCS), in the Department of the Treasury, tors, advanced computer systems, and is the principal border-enforcement agency. Cus- sophisticated surveillance equipment. Reflecting toms conducts a wide range of statutory and regu- the high priority for drug interdiction, over 650 latory activities ranging from interdicting and seiz- National Guard personnel in twenty-seven states ing contraband entering the United States to have been assigned to assist Customs with inspec- intercepting illegal export of high-technology tion of containerized cargo, vessels, and aircraft. items. Customs officers also assist over forty other Customs has also developed major aviation and federal agencies with border-enforcement responsi- marine interdiction programs since the 1970s. Ini- bilities, including public-health threats, terrorists, tially dependent on aircraft borrowed from the De- agricultural pests, and illegal aliens. partment of Defense (DOD) and seized from smug- With a fiscal year 1993 budget of over $1.6 bil- glers, Customs now operates over 130 aircraft and lion and 18,000 employees, Customs is a major 150 vessels. Customs supports a series of Com- revenue-producing agency; it collected $21.5 bil- mand, Control, Communications, and Intelligence lion in duty, taxes, and fees in 1993. Centers (known as C3I) to provide coordinated tactical control for air interdiction. Using sophisti- CUSTOMS ROLE IN cated aircraft, helicopters, and vessels, Customs DRUG ENFORCEMENT works closely with the U.S. Coast Guard and U.S. military forces in providing surveillance, intercep- Customs is both a leader and a major player in tion, and deterrence against drug smuggling by air stopping drug contraband from entering the United and sea. States. Approximately $570 million of the 1993 In addition to the tactical interdiction program, Customs budget was related to antidrug operations. Customs conducts investigations of financial re- Customs’ inspection and control function is directed at stopping illegal entry of drugs and other porting and smuggling violations, developing both contraband while accommodating the normal traf- criminal and civil cases. USCS is represented in fic of persons and cargo entering the United States various interagency enforcement task forces. and enforcing export laws. Customs is an active participant in developing As the federal lead agency at U.S. ports of entry, federal drug policy and has used its high public Customs inspects individuals, conveyances, mail, visibility to contribute to national drug-abuse pre- and cargo entering the United States at these ports vention efforts, emphasizing ‘‘user responsibility’’ (land, sea, and air). Customs has broad search and and drug education. Historically, Customs has pro- seizure authority at the U.S. borders and handles vided staff assistance to executive and congressio- enormous workloads; for example, some 450 mil- nal drug-policy offices and committees. The Cus- lion international travelers arrive at U.S. borders toms commissioner was included in the Executive each year. Customs operates a comprehensive com- Office of the President (EOP) drug-policy coordi- puterized border information system and uses other nating activities, including the Principals’ Group, domestic and international drug-intelligence net- the Oversight Working Group, the National Nar- works. Priority efforts are targeted on illegal traffic cotics Border Interdiction System, and others. The in precursor chemicals, improving interdiction in- commissioner of Customs chairs the Office of Na- telligence, and special high-intensity enforcement tional Drug Control Policy’s (ONDCP) Border In- operations, particularly along the southwest terdiction Committee, with subcommittees that de- border. velop and guide the implementation of strategies As a large, multipurpose border-control agency, for air, land, and sea interdiction. Customs also Customs has considerable flexibility in determining works with the international Customs Coordinating the most effective means to meet its responsibilities. Council in developing new procedures and tech- The traditional approach involves the physical niques. presence of uniformed officers at the border to detect and seize violators and contraband. Customs (SEE ALSO: Anslinger,Harry J.,and U.S. Drug Pol- emphasizes development of the best possible detec- icy; Drug Interdiction; International Drug Supply tion capabilities and information systems, includ- Systems; Operation Intercept; Zero Tolerance) U.S. GOVERNMENT AGENCIES: U.S. Public Health Service Hospitals 1305

BIBLIOGRAPHY lated to addiction. This was an advanced conception, for treatment of narcotic addiction until then PRICE, C. E., & KELLER, M. (1989). The U.S. Customs had been focused almost exclusively on the PHYSI- Service,a bicentennial history . Washington, DC: De- CAL DEPENDENCE. The initial treatment programs partment of the Treasury, U.S. Customs Service. (An at both hospitals emphasized residence in a drug- overview of 200 years of Customs history; a chapter free environment for at least six months, during on drug enforcement.) which time the patient could not only recover from U.S. EXECUTIVE OFFICE OF THE PRESIDENT, Office of Drug the physical dependence but perhaps also overcome Abuse Policy. (1977) Border management and in- the mental difficulties or learn to adapt to them terdiction—an interagency review. Washington, DC. without using drugs. While all patients received (Description of borders and border responsibilities.) psychological help in the form of encouragement U.S. EXECUTIVE OFFICE OF THE PRESIDENT, Office of Na- and persuasion, only small numbers received for- tional Drug Control Policy. (1992). National drug mal psychotherapy. That was because few of the control strategy. Washington, DC. staff were trained in psychotherapy. All patients U.S. EXECUTIVE OFFICE OF THE PRESIDENT, Office of Na- considered physically able had work assignments, tional Drug Control Policy. (1992). National drug and all had access to educational and vocational control strategy budget summary. Washington, DC. services, recreation, and religious activities. Treat- RICHARD L. WILLIAMS ment of voluntary patients was hindered because most left during or shortly after WITHDRAWAL treatment (often to return to lower doses of their U.S. PublicHealth ServiceHospitals In drug—before readmission). In 1948, the research 1929, President Herbert C. Hoover signed a law division of the Lexington hospital reported that a enacted by the U.S. Congress to establish two fed- new synthesized narcotic drug called METHADONE eral institutions for treatment of narcotic addiction. was effective in the treatment of opiate withdrawal. The principal purpose of the institutions was to Methadone substitution followed by a gradual de- confine and treat persons addicted to narcotic crease of its dose subsequently became the stan- drugs who had been convicted of offenses against dard treatment for morphine and heroin with- the United States. However, the law also provided drawal in the United States. Also in 1948 the for voluntary admission and treatment of addicts research division of the Lexington hospital was who were not convicted of any offense. The two administratively separated from the hospital, re- institutions were named U.S. public health service named the Addiction Research Center (ARC) and hospitals. One was opened in 1935 at Lexington, made a part of the National Institute of Mental Kentucky, and the other in 1938 at Fort Worth, Health (NIMH). Texas. The Lexington hospital had a capacity of 1,200 patients; the Fort Worth hospital could ac- SECOND PERIOD, 1950–1966 commodate 1,000 patients. From opening to closure in 1974, the hospitals admitted over 60,000 After World War II, the prevalence of HEROIN narcotic addicts; because of readmissions, the total addiction in the United States markedly increased. admissions exceeded 100,000. Most of the admis- Heroin replaced morphine as the primary narcotic sions were voluntary. The term narcotic addiction used. Annual admissions to the two hospitals dou- has been replaced in modern diagnostic terminol- bled from the 1940s to the 1950s. The prewar ogy by the term opioid dependence, but in this addicts differed from their postwar counterparts. discussion the older term is retained because it was More of the postwar addicts came from large cities, regularly used during the era reviewed here. The and more came from minority groups (mainly history of the hospitals is divided into three periods. black and Hispanic). While residence in a drug-free environment continued as a major feature, new psychosocial treat- FIRST PERIOD, 1935–1949 ments were made a part of the program. Psychoan- From the start, the hospitals were designed to alytically oriented PSYCHOTHERAPY was offered, treat not only the physical dependence but also the but few patients seemed willing or able to engage in mental and emotional problems thought to be re- this form of therapy. Group therapy, however, 1306 U.S. GOVERNMENT AGENCIES: U.S. Public Health Service Hospitals seemed more acceptable, and most patients partici- communities for drug-abuse treatment programs pated in it to some extent. Influenced by new con- made the centers less needed. The Fort Worth cepts of the therapeutic community, staff members Center was closed in 1971 and the Lexington Cen- tried to improve the quality of the patients’ psycho- ter in 1974. The facilities were transferred to the social experience in the hospital. Federal Bureau of Prisons and were converted into correctional institutions. THIRD PERIOD, 1967–1974 In 1967, a research mission was assigned to the HISTORIC ROLES OF THE HOSPITALS two hospitals, and each was renamed a National For approximately three decades, from the Institute of Mental Health Clinical Research Cen- 1930s into the 1960s, the two Public Health Ser- ter. Before the research mission could be developed, vice hospitals were almost the only institutions in however, a new clinical mission was assigned to the the United States engaged in the study and treat- two institutions. The NARCOTIC ADDICT ment of narcotic addiction. They became interna- REHABILITATION ACT (NARA), enacted in 1966, tional centers of expertise. Staff members pub- provided for the CIVIL COMMITMENT of addicts in- lished many reports on the psychosocial stead of prosecution on a criminal charge, or sen- characteristics of the addicts, the treatment pro- tence after conviction, or by petition with no crimi- grams, treatment outcomes, and related topics. nal charge. The law authorized the Public Health Many clinicians and investigators who worked at Service to enter into contracts with any public or Lexington and Fort Worth left these institutions to private agencies to provide examination or treat- become leaders in treatment of or research on nar- ment of addicts committed under the NARA, but it cotic addiction at other locations. Despite great ef- was decided to use the two clinical research centers forts, however, the hospitals failed to develop an to implement the act quickly. Admission of pris- enduring cure for narcotic addiction. Hospital oners and voluntary patients was phased out, and treatment often produced a temporary remission in the centers concentrated on service to the NARA the addiction, but relapse within a year was the patients. From 1967 through 1973, over 10,000 typical outcome. NARA patients were admitted to the two centers. Nearly all were admitted under the provision of the law that permitted commitment with no federal (SEE ALSO: Opioid Dependence; Treatment,His- criminal charge. tory of; Wikler’s Pharmacologic Theory of Drug The NARA civil commitment seemed a promis- Addiction) ing way to eliminate the problem of voluntary patients who signed out prematurely. In practice, it BIBLIOGRAPHY only reduced the problem. Patients learned that LEUKEFELD,C.G.,&TIMS,F.M.(EDS.) (1988). Com- commitment could be avoided or terminated if they refused to participate in treatment activities or en- pulsory treatment of drug abuse: Research and clini- gaged in disruptive or antagonistic behavior. Only cal practice. National Institute on Drug Abuse Re- about one-third of the NARA patients completed a search Monograph 86. DHHS Publication no. (ADM) six-month period of institutional treatment. 88-1578. Rockville, MD: U.S. Department of Health The NARA program led to the closure of the and Human Services. two centers. As more contracts were made with MARTIN, W. R., & ISBELL,H.(EDS.) (1978). Drug addic- local facilities for examination and treatment of tion and the U.S. Public Health Service. DHEW Pub- NARA patients, admissions to the two centers de- lication no. (ADM) 77-434. Rockville, MD: U.S. De- creased. In addition, a new federal program, partment of Health, Education, and Welfare. started in the late 1960s, of grants to states and JAMES F. MADDUX V

VALIUM See Benzodiazepines CULTURAL BELIEFS IN ADDICTION Cultural differences are among the most powerful determinants of the patterns of substance use VALUES AND BELIEFS: EXISTENTIAL and the proclivity to addiction (Heath, 1982). For MODELS OF ADDICTION Existential example, moderate drinking is inculcated as an models of addiction focus on beliefs, attitudes, and early and firm cultural style among Mediterranean values of the drug users. For example, psycholo- ethnic groups, the JEWS and the CHINESE. Such gists have found that problem drinkers and alco- cultural socialization incorporates beliefs about the holics anticipate greater benefits and more power- power of ALCOHOL and the nature of those who ful effects from drinking than do other drinkers. overindulge or misbehave when drinking. Groups These beliefs precede actual drinking experiences such as the Irish, which invest alcohol with the (Miller, Smith, & Goldman, 1990). power to control and corrupt their behavior, have Beliefs about oneself and about the role of drugs high levels of ALCOHOLISM (Vaillant, 1983). In or alcohol in one’s life are sometimes called existen- contrast, Jews, Italians, and Chinese believe that those who overdrink are displaying poor self-con- tial models (Greaves, 1980). Khantzian (1985) has trol and/or psychological dependence, rather than proposed that addicts use drugs to offset or address responding to the power of the alcohol itself (Glas- specific problems they believe they have, such as a sner & Berg, 1984). Similar cultural variations lack of confidence in social-sexual dealings, a view occur in views toward drugs such as MARIJUANA, sometimes referred to as the adaptive model of ad- NARCOTICS,PSYCHEDELICS, and COCAINE. diction. According to Peele (1985), the individual Cultural recipes for moderate consumption of becomes addicted to a substance because it fulfills alcohol and other drugs have been developed, al- essential intrapsychic, interpersonal, and environ- though systematic cross-cultural empirical support mental needs. for these models is weak. One cross-cultural survey Views about oneself in regard to a substance- of addictive (loss-of-control) behavior is Mac- abuse problem are crucial for dealing with this Andrew and Edgerton’s (1969) Drunken Comport- problem. If the client and treatment personnel see ment, which describes cultural beliefs that encour- the problem differently, in viewing it as a disease or age overconsumption and drunken excesses. Yet not, for example, treatment will generally not cultural attitudes about alcohol and other drugs in succeed. relation to their misuse are generally regarded as

1307 1308 VENTRAL TEGMENTAL AREA

cultural oddities, rather than scientifically mean- pedic handbook of alcoholism (pp. 426–440). New ingful factors in models of addiction. York: Gardner Press. KHANTZIAN, E. J. (1985). The self-medication hypothesis VALUES of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142, If individual and cultural beliefs have been given 1259–1264. short shrift in addiction theories, then values have MACANDREW, C., & EDGERTON, B. (1969). Drunken com- been considered in such models primarily as illus- portment: A social explanation. Chicago: Aldine. trations of moralistic prejudice. MILLER, P. M., SMITH,G.T.,&GOLDMAN, M. S. (1990). Whereas a layperson might condemn the values Emergence of alcohol expectancies in childhood. of a mother who uses drugs or drinks excessively Journal of Studies on Alcohol, 51, 343–349. during pregnancy or of a person who assaults PEELE, S. (1987). A moral vision of addiction: How peo- others when drunk or using drugs, some pharmaco- ple’s values determine whether they become and re- logically based theorists instead emphasize the po- main addicts. In S. Peele (Ed.), Visions of addiction tency of the drug and the irrevocable need of the (pp. 201–233). Lexington, MA: Lexington Books/ person to obtain the drug at the cost of any other Heath. consideration whatsoever. PEELE, S. (1985). The meaning of addiction: Compulsive Peele (1987) turned this model on its head— experience and its interpretation. Lexington, MA: claiming that people become addicted due to a fail- Lexington Books/Heath. ure of other values that maintain ordinary life in- REINARMAN, C., WALDORF,D.,&MURPHY, S. (1991). volvements. In Peele’s view, personal values influ- Cocaine changes: The experience of using and quitt- ence whether people use drugs, whether they use ing. Philadelphia: Temple University Press. them regularly, whether they become addicted, and VAILLANT, G. E. (1983). The natural history of alcohol- whether they remain addicted. These values in- ism. Cambridge: Harvard University Press. cluded prosocial behavior (including achievement, STANTON PEELE concern for others, and community involvement), self-awareness and intellectual activity, moderation and healthfulness, and self-respect. Evi- VENTRAL TEGMENTAL AREA The dence for the role of values in addiction are the ventral tegmental area, (VTA), is a very important explicit values people cite as reasons for giving up brain area in the field of drug abuse. It is one of only addictions to cocaine, alcohol, and nicotine two main areas that contain DOPAMINE cell bodies. (Reinarman, Waldorf, & Murphy, 1991). The MESOLIMBIC DOPAMINE pathway originates in the VTA. Dopamine neurons in the VTA project to (SEE ALSO: Addiction: Concepts and Definitions; areas of the brain associated with emotion and mo- Adjunctive Drug Taking; Asia, Drug Use in; Causes tivation, the so-called limbic areas. However, the of Substance Abuse; Expectancies; Religion and projection to the NUCLEUS ACCUMBENS is the most Drug Use) important in understanding the action of drugs of abuse, especially psychostimulants. In addition, BIBLIOGRAPHY neurons in the nucleus accumbens and other limbic areas project to the VTA, providing the substrate GLASSNER, B., & BERG, B. (1984). Social locations and for many neurochemicals to modulate the dopa- interpretations: How Jews define alcoholism. Journal mine cells in the VTA. of Studies on Alcohol, 45, 16–25. There are two main experimental paradigms GREAVES, G. B. (1980). An existential theory of drug used in animals to assess the effects of drugs and dependence. In D. J. Lettieri, M. Sayers, & H. W. endogenous neurotransmitters, such as DYNOR- Pearson (Eds.), Theories on drug abuse (pp. 24–28). PHIN, on these dopaminergic cells at the level of the Washington, DC: U.S. Government Printing Office VTA. Chemicals can be injected directly into the (DHHS Pub. No. ADM 80-967). VTA in order to study their effects. Conditioned HEATH, D. B. (1982). Sociocultural variants in alcohol- place preference is a method, which allows the ism. In E. M. Pattison & E. Kaufman (Eds.), Encyclo- animal to be tested for the REINFORCING properties VIETNAM: DRUG USE IN 1309 of a chemical in a drug free state. In addition, increases in locomotor activity can be measured, psychomotor stimulants in addition to being rewarding increase locomotor activity, and one substrate underlying this increase is the VTA. The most extensively studied drugs of abuse, psychostimulants and opiates, both interact with the mesolimbic dopamine system. Future studies fully elucidating the modulation of VTA dopamine neurons will greatly contribute to the understanding of the mechanism of action of drugs of abuse, and may lead to the development of medications to treat drug abusers. Two American GIs exchange vials of heroin in STEPHANIE DALL VECCHIA-ADAMS their living quarters in Quang Tri Province, South Vietnam. (᭧ Bettmann/CORBIS)

VIETNAM: DRUG USE IN In the spring of of drug use in the military. The suggested plan 1971, two members of Congress (John Murphy and included urine testing, to detect heroin use, and Robert Steele) released an alarming report alleging treatment rather than court martial when drug use that 15 percent of U.S. servicemen in Vietnam were was detected. President Nixon endorsed the plan addicted to HEROIN. The armed forces were at- and the military responded with such remarkable tempting to cope with the drug problem by com- rapidity that, on June 17, 1971, less than six weeks bining military discipline with ‘‘amnesty.’’ Anyone from the time it was proposed, the plan was initi- found using or possessing illicit drugs was subject ated in Vietnam. to court martial and dishonorable discharge from In fact, there was no way to know whether the the service; but drug users who voluntarily sought new approach would be better than the old one, no help might be offered ‘‘amnesty’’ and brief treat- reliable information on the actual extent of drug ment. This policy apparently was having little im- use and addiction, and no solid information on pact, since heroin use had increased dramatically which to base estimates of how many servicemen over the preceding year and a half. would require additional treatment after discharge. Because the United States was trying to negoti- To obtain information on the extent of drug use, the ate settlement of the war, military forces in Viet- effectiveness of treatment, and the relapse rates it nam were being rapidly reduced. About 1,000 men would be necessary to find and interview the ser- were being sent back to the United States each day, vicemen at time of discharge and at various inter- many of them to be discharged shortly thereafter to vals after discharge. civilian life. If the reported rate of heroin addiction In June 1971, President Nixon also announced among servicemen were accurate, this rapid reduc- the formation of the SPECIAL ACTION OFFICE FOR tion in force meant that hundreds of active heroin DRUG ABUSE PREVENTION (SAODAP) charged with addicts were being sent home each week. Con- coordinating the many facets of the growing drug cerned about the social problems that could ensue problem and named Dr. Jaffe as its first director. from such an influx of addicts, President Richard One of the first tasks of the office was to evaluate M. Nixon charged his staff with seeking an effective the results of the new drug policy for the military, response. Domestic Council staff members Jeffrey especially as it was implemented in Vietnam. Donfeld and Egil Krogh, Jr., sought advice from SAODAP arranged for Dr. Lee Robins, of Washing- Dr. Jerome H. Jaffe, then on the faculty of the ton University in St. Louis, to obtain records from University of Chicago, who had previously pre- the Department of Defense and the Veterans Ad- pared a report for the president on the development ministration to conduct the study. The findings on of a national strategy for the treatment of drug drug use prior to and during service are summa- dependence. Dr. Jaffe recommended a radical rized here. The drug-using behaviors of the ser- change in the policy for responding to the problem vicemen after their return to civilian life are de- 1310 VIETNAM: DRUG USE IN

scribed in a separate article (see VIETNAM: their return from Vietnam, after the great majority FOLLOW-UP STUDY). had been discharged (Robins et al., 1975). Previ- Around 1970, before going overseas, about half ous studies in Vietnam (Stanton, 1972; Roffman & the army’s enlisted men had had some experience Sapol, 1970; Char, 1972) or among men still in with illicit drugs. However, only 30 percent had service after return (Rohrbaugh et al., 1974) were tried any drug other than MARIJUANA. At that time, less reliable, because of difficulties in collecting a the most common civilian drugs other than mari- random sample, use of questionnaires rather than juana were BARBITURATES and AMPHETAMINES. Be- interviews (which can lead to careless responses or fore going to Vietnam, only 11 percent of soldiers failure to answer completely), and because the sur- had tried an OPIATE, and those who did so gener- veys were being done by the army itself, while the ally took cough syrups containing CODEINE, not men were still subject to possible disciplinary heroin or OPIUM. action. The men sent to Vietnam had either been The standard tour of duty for Vietnam soldiers drafted or had enlisted. Toward the end of the war, was twelve months. Drug use typically began soon when drug use in the United States was highest, after arrival in Vietnam, showing that it was not at draftees were chosen by a lottery designed to make all difficult to find a supplier. Older men used less selection less susceptible to social-class biases. This than younger soldiers, career soldiers less than produced draftees who were a reasonably represen- those serving their first term. Drug experience be- tative sample of young American men. Those who fore induction was a powerful predictor of use in enlisted voluntarily, however, who made up about Vietnam (Robins et al., 1980). Essentially all those 40 percent of the armed forces, were disproportion- with drug experience before enlistment used drugs ately school dropouts. Many of them enlisted before in Vietnam. Of course, there were also some sol- reaching draftable age because of their limited oc- diers who used drugs there for the first time. cupational opportunities. They also arrived in Viet- One interesting observation was that men who nam with considerably more drug experience than drank ALCOHOL in Vietnam tended not to use opi- the draftees. ates, and opiate users tended not to drink (Wish et Men who were sent to Vietnam before 1969 al., 1979). This is a very different pattern from the found marijuana plentiful but little else in the way one seen in the same men both before and after of illicit drugs (Stanton, 1976). Some amphet- Vietnam, when drinkers were much more likely to amines were available—in part, because the mili- use illicit drugs than abstainers. tary issued them to help men stay alert on recon- Soldiers who used drugs had more disciplinary naissance missions. In 1969, heroin and opium problems, on average, than those who abstained. began to arrive on the scene, and by 1970–1971 However, the great majority of drug users received these opiates were very widely available. Marijuana little or no disciplinary action and were honorably was still the most commonly used illicit drug, but discharged. Although there were instances in which opiates outstripped amphetamines and barbitu- drug use impaired a soldier’s combat readiness, rates in availability. Heroin and opium were rela- evidence is lacking that it had much impact on tively cheap and very pure, so pure that the soldiers soldiers’ ability to carry out orders or wage war. could get ample effect by smoking heroin in combi- OBACCO nation with T or marijuana. This made opi- (SEE ALSO: Addiction: Concepts and Definitions; ates appealing to men who would have been reluc- Drug Testing and Analysis; Military, Drug and tant to inject them. Alcohol Abuse in the U.S.) At the height of the use of opiates, in 1971, almost half the army’s enlisted men had tried them; BIBLIOGRAPHY of those who tried them, about half used enough to develop the hallmarks of addiction—TOLERANCE CHAR, J. (1972). Drug abuse in Vietnam. American Jour- and WITHDRAWAL symptoms (Robins et al., 1975). nal of Psychiatry, 129(4), 123–125. Marijuana use was even more common; about two- ROBINS, L. N., HELZER, J. E., & DAVIS, D. H. (1975). thirds of these soldiers used it. The estimates come Narcotic use in Southeast Asia and afterward: An from an independent survey of a random sample of interview study of 898 Vietnam returnees. Archives of army enlisted men eight to twelve months after General Psychiatry, 32(8), 955–961. VIETNAM: FOLLOW-UP STUDY 1311

ROBINS, L. N., HELZER, J. E., HESSELBROCK, M., & WISH, Veterans Administration, the National Institute of E. (1980). Vietnam veterans three years after Viet- Mental Health, and the Department of Labor. The nam: How our study changed our view of heroin. In L. goal was to learn how many men had actually been Brill and C. Winick (Eds.), Yearbook of substance use addicted in Vietnam, whether those addicted would and abuse. New York: Human Science Press. continue to use heroin after return and how many ROFFMAN, R. A., & SAPOL, E. (1970). Marijuana in Viet- would be readdicted after return. The study was nam: A survey of use among Army enlisted men in the conducted by Washington University in St. Louis, two Southern corps. International Journal of the Ad- with Lee N. Robins, Ph.D., as principal investigator dictions, 5(1), 1–42. (Robins, 1973, 1974; Robins et al., 1975). ROHRBAUGH, M., EADS,G.,&PRESS, S. (1974). Effects of The group believed to be most at risk of addic- the Vietnam experience on subsequent drug use tion was army enlisted men, who spent their whole among servicemen. International Journal of the Ad- tour of duty on Vietnam soil, rather than on ships dictions, 9(1), 25–40. or in the air like men in the navy or air force. Thus, STANTON, M. D. (1976). Drugs, Vietnam, and the Viet- two groups of 500 army enlisted men were selected nam veteran: An overview. American Journal of Drug for the follow-up, a random sample of men return- & Alcohol Abuse, 3(4), 557–570. ing in September 1971, and a sample of men whose STANTON, M. D. (1972). Drug use in Vietnam: A survey urines had been positive when tested just prior to among Army personnel in the two Northern corps. departure for the United States that month. The Archives of General Psychiatry, 26(3), 279–286. overlap between the two groups selected made it WISH, E. D., ROBINS, L. N., HESSELBROCK, M., & HELZER, possible to estimate what proportion of all army J. E. (1979). The course of alcohol problems in Viet- enlisted men had tested positive. Military records of nam veterans. In M. Galanter (Ed.), Currents in alco- all those selected were reviewed to verify the date of holism. New York: Grune & Stratton. their departure from Vietnam and to obtain a civilian address and the names of close relatives who LEE N. ROBINS would know where to contact them. Records were also used to verify the men’s reports of drug problems in the service. To protect from subpoena the VIETNAM: FOLLOW-UP STUDY In the confidentiality of the information given by the men, summer of 1971, the U.S. military forces in Viet- a certificate of confidentiality was obtained. Then nam were being rapidly reduced. To deplete the each interview was identified only by a randomly forces there quickly, many men were being sent selected number placed on its mailing envelope but home before the usual tour of twelve months was not on the interview proper. The interview was then complete. A urine-screening program was estab- mailed to another country, where a second random lished in July to detect the recent use of illicit drugs identification number was selected to replace the by men scheduled to depart Vietnam for the United original one. A list connecting the first number to States. Those detected as positive were kept for DE- identifiers was held in the United States, and a list TOXIFICATION for about seven days, retested, and linking the first number to the second one was kept sent home only if they had a negative test. The abroad, so that no one in either country could link urine screening was initiated in response to great names to interviews. concern that many members of the military had Almost 900 men were personally interviewed become addicted to HEROIN in Vietnam. The fear eight to twelve months after their return from Viet- was that they might continue their addiction in the nam. The response rate was extraordinary: 96 per- United States. Because the great majority of those cent of the sample initially selected were personally returning were due for discharge on return, the interviewed. The men were extremely frank—97 MILITARY would have no further control over them. percent of men whose military record showed drug They might present overwhelming problems to the use had reported it to the interviewer. Two findings legal system and to veterans’ hospitals. were especially surprising. First, use of narcotics in To learn whether this fear was justified, the SPE- Vietnam was much more common than the military CIAL ACTION OFFICE FOR DRUG ABUSE PREVENTION had estimated. Almost half (43%) of the army (SAODAP) launched a follow-up study with the enlisted men had used heroin or opium in Vietnam, collaboration of the Department of Defense, the and 20 percent had been addicted to narcotics 1312 VIOLENCE AND SUBSTANCE ABUSE

there. Second, only a tiny proportion (12%) of Brill & C. Winick (Eds.), Yearbook of substance use those addicted in Vietnam became readdicted in and abuse. New York: Human Science Press. the year after return (Robins et al., 1974). Fol- LEE N. ROBINS low-up again two years later showed that this low rate of readdiction continued (Robins et al., 1980). During their second and third years home, addic- VIOLENCE AND SUBSTANCE ABUSE tion rates among men drafted were not significantly See Crime and Drugs; Family Violence and Sub- greater than among men who qualified for the draft stance Abuse; Gangs and Drugs; International Drug but did not serve. This surprisingly low rate of Supply Systems relapse could not be attributed to abstention from narcotics after return; half of those addicted in Vietnam did use again after return. Those who VITAMINS Vitamins are organic substances went back to narcotics were predominantly men that are required in small amounts for normal who had used drugs before they entered the service. functioning of the body. Lack of adequate quan- Although the principal finding of this study was tities of vitamins results in well-known deficiency that heroin addiction in Vietnam had a much better diseases, such as scurvy from Vitamin C defi- outcome than expected, there were men whose ad- ciency and rickets from Vitamin D deficiency in diction continued on return home. Treatment for childhood. For the most part, vitamins are not them was no more effective than for men who de- synthesized by the body but are found in a vari- veloped addiction in the United States (Robins, ety of foods, hence the need for a well-balanced 1975). diet or supplementation by taking the vitamins separately. (SEE ALSO: Addiction: Concepts and Definitions; In the United States, daily minimum require- Drug Testing and Analysis; Opioid Dependence; ments for vitamins are recommended, and periodi- Treatment; Vietnam: Drug Use in) cally reassessed, by the Food and Nutrition Board of the National Academy of Science—National Re- search Council. Some professionals advocate tak- BIBLIOGRAPHY ing larger amounts of certain vitamins is for better ROBINS, L. N. (1975). Drug treatment after return in health or for disease prevention or therapy. The Vietnam veterans. Highlights of the 20th annual con- question of whether vitamins are drugs is, in one ference, Veterans Administration Studies in Mental sense, a semantic issue. Sometimes, very high doses Health and Behavioral Sciences. Perry Point, MD: of a vitamin can actually be used as a medication. Central NP Research Laboratory. For example, in very high doses—twenty or more ROBINS, L. N. (1974). The Vietnam drug user returns, times higher than needed to prevent the vitamin Special Action Office Monograph, Series A, No. 2. deficiency disease pellagra—niacin, a member of Washington, DC: U.S. Government Printing Office the B vitamin complex, lowers blood levels of cholesterol and triglycerides and niacin is commonly ROBINS, L. N. (1973). A follow-up of Vietnam drug users, prescribed for this purpose. Special Action Office Monograph, Series A, No. 1. It is possible to OVERDOSE and have serious side Washington, DC: Executive Office of the President. effects from large quantities of certain vitamins, ROBINS, L, N., DAVIS, D. H., & NURCO, D. N, (1974). such as vitamins A and D. Therefore, taking larger How permanent was Vietnam drug addiction? Ameri- than needed amounts of vitamins should be done can Journal of Public Health, 64(Suppl), 38–43. only with the advice of a physician. Deficiencies in ROBINS, L. N., HELZER, J. E., & DAVIS, D. H. (1975). vitamin intake can occur under a variety of situa- Narcotic use in Southeast Asia and afterward: An tions including poverty, dieting, or certain disease interview study of 898 Vietnam returnees. Archives of states where antibiotics or other factors reduce vi- General Psychiatry, 32(8), 955–961. tamin absorption. Individuals who drink large ROBINS, L. N., HELZER,J.E.HESSELBROCK, M., & WISH, quantities of ALCOHOL, for example, without ade- E. (1980). Vietnam veterans three years after Viet- quate attention to diet often become deficient in

nam: How our study changed our view of heroin. In L. some vitamins, such as B1 (thiamine), and may VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview 1313 require their administration to avoid serious and inﬂuences that decrease the likelihood of drug use. permanent toxicity. Prolonged serious shortages of Vulnerability refers to the sum total of an individ-

Vitamin B1 can cause the death of certain NEURONS ual’s risk and protective factors. It deﬁnes the over- in the brain, a situation that leads to confusion and all likelihood of drug use. Individuals with many severe impairment of short-term memory (the risk factors and few protective factors are more Wernicke-Korsakoff syndrome). likely than individuals with few risk factors and many protective factors to use drugs. (SEE ALSO: Complications) GOALS OF BIBLIOGRAPHY VULNERABILITY RESEARCH

MARCUS, R., & COULSTON, A. M. (1990). The vitamins. In In vulnerability research, attempts are made to A. G. Gilman et al. (Eds.), Goodman and Gilman’s identify risk and protective factors for both drug the pharmacological basis of therapeutics, 8th ed. use and drug dependence, refine existing risk and New York: Pergamon. protective factors by enhancing their specificity in MICHAEL J. KUHAR predicting drug use, reduce the number of risk and protective factors to their most fundamental number, and understand the environmental and genetic influences (i.e., mechanisms) that underlie risk and VULNERABILITY AS CAUSE OF SUB- protective factors. This section contains some STANCE ABUSE Risk-Factor Identification. A large number articles that discuss one of several Causes of Sub- of risk factors for substance abuse have been re- stance Abuse—vulnerability. In addition to an ported (Table 1). They include characteristics that Overview article, the following topics are discussed fall within the demographic, environmental, socio- as vulnerability factors: Gender; Genetics; the Psy- cultural, family, personality, behavioral, psychiat- choanalytic Perspective; Race; Sensation Seeking; ric, and genetic domains. Among these are POV- Sexual and Physical Abuse; and Stress. For more ERTY, unemployment, poor quality of education, information, see Comorbidity and Vulnerability, racial discrimination, ready availability of drugs, Families and Drug Use, and Poverty and Drug Use. family discord, family alcohol and drug use, sexual abuse, lack of family rituals, neuropsychological deficits, childhood aggressiveness, low self-esteem, An Overview There are marked individual teenage pregnancy, rebelliousness, delinquency, differences in drug use and abuse. Some people drug use by peers, mental health problems, and never use drugs although drugs may be readily cultural alienation. available to them. Others use drugs sporadically or A number of protective factors for substance regularly for years but never escalate their use to abuse have also been reported (Table 2); however, drug DEPENDENCE. Others become chronic, com- these are considerably fewer than the reported pulsive users and have difficulty functioning with- number of risk factors, primarily because less at- out drugs. These individual differences in drug-use tention has been focused on their identification. In patterns are the result of a combination of environ- general, the protective factors that have been re- mental and genetic factors. Environmental factors ported are the opposite of known risk factors. As include the experiences of an individual, such as such, they include an adequate income, high-qual- family and social conditions, as well as other condi- ity schools, positive self-esteem, and the like. tions under which the person lives. Genetic factors Given the fact that a large number of risk factors refer to the genes that are passed down from parent are commonly present in modern society, many to child and which are shared in part by other people possess multiple risk factors for drug use. family members. Becoming a drug user is not an inevitable outcome Environmental and genetic factors combine to for these people, however, since many individuals produce risk factors, which are influences that in- with multiple risk factors do not become drug crease the likelihood of drug use. They may also users. Similarly, some individuals who are drug combine to produce protective factors, which are users or drug dependent have few risk factors. 1314 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview 1315

Risk-Factor Specificity. Unfortunately, ployed are factors statistically associated with her- many risk factors are so broadly defined that they oin addiction, it is important to remember that this are not useful as predictors. For example, we know is only a statistical association. Most individuals that males are more likely than females to use illicit with these characteristics never become heroin ad- drugs and that underemployed people are more dicts. Thus, underemployed males represent a cate- likely than employed people to become HEROIN gory that includes a large number of individuals addicts. Being male or being underemployed, how- who are not actually at risk for heroin addiction. ever, is not a useful predictor of drug use. Most Increasing specificity in risk factors is important males do not use illicit drugs and most underem- because it allows the resources for PREVENTION to ployed people are not heroin addicts. Combining be directed toward the people in greatest need. GENDER and employment status into a single risk Specificity also minimizes the problem of inappro- factor (i.e., the risk factor of being an underem- priately stigmatizing people because they have a ployed male) increases specificity somewhat, and characteristic that is statistically associated with combining these factors with other risk factors drug use. (e.g., having an ANTISOCIAL PERSONALITY disorder) Fundamental RiskFactors. Because of their increases the predictive value even more. current lack of etiological specificity, concern has The problem with lack of specificity is that it been expressed about the usefulness of the large leads to overinclusion of people in risk groups. number of risk factors that have been reported for Many people are thus included in a risk group who drug use. Over seventy risk factors for drug use are not actually at risk of becoming drug users. For have been reported to date, but it is not clear if they example, although being male and being underem- are all independent factors. Some reported risk fac- 1316 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview

tors may be the product of other risk factors. For sonality characteristics (e.g., SENSATION SEEKING, example, neuropsychological deficits may precipi- risk taking) that increases the likelihood of drug tate learning problems, which in turn may lead to use and that may be genetically determined. Ge- excessive CHILDHOOD aggressiveness. Similarly, netic influences may also contribute to the develop- family alcohol and drug use may result in family ment of drug dependence by altering the effects of a discord, and poor-quality schools may contribute drug (e.g., causing greater euphoria in some people both to underemployment and HOMELESSNESS. than in others). In addition, they may contribute to Other risk factors may reflect different manifes- both drug use and dependence by being responsible tations of more basic factors. For example, rebel- for the absence of normal protective factors (e.g., liousness, DELINQUENCY, and aggressiveness may failure to experience a hangover after excessive al- reflect a more basic personality characteristic or be cohol use). The specific genetic mechanisms in- the result of common genetic influences. Although volved will be the genes (as yet unidentified) that the actual number of basic risk factors in drug use contribute to personality development, drug re- is not known, they are certain to be fewer than the sponse, and other important components. large number of risk factors reported to date. The The specific mechanisms that control drug use large number of reported risk factors probably re- are undoubtedly the same environmental and ge- flects the highly interrelated nature of the influ- netic mechanisms that control human behavior in ences involved in drug use. general. The mechanisms responsible for the initial Underlying-mechanism Identification. A drug use and for the progression to regular use and risk factor may itself be a product of the interaction possibly drug dependence may not be the same. among environmental and genetic influences, or it Once these mechanisms are understood, however, it may only be correlated with those influences. In will be possible to more directly address risk factors either case, it is useful for predicting drug use. To for drug use by means of intervention measures. most efficiently prevent drug use, however, it is The ultimate goal of those engaged in vulnerability necessary to understand the basic mechanisms that research is to develop efficient, cost-effective pre- control drug use. As one increases the specificity of vention programs that specifically target individu- risk factors and reduces them to their most funda- als at risk for both drug use and drug dependence. mental number, one comes ever closer to identifying the specific environmental and genetic mech- VULNERABILITY anisms involved. RESEARCH STRATEGIES At present, most risk factors are hypothetical constructs and only conceptually defined. Conse- A variety of strategies are available for achieving quently, the risk factor does not identify the mech- the goals of vulnerability research. They include anisms responsible for drug use. To understand both epidemiological and experimental studies, ge- how the risk factor increases the likelihood of drug netic studies, and ANIMAL RESEARCH. use, one must identify the mechanisms involved. Cross-sectional Epidemiological Studies. For example, having drug-using peers is recognized Risk factors are initially identified through their as a risk factor for drug use (because drug use by statistical association with drug use. Most of the ADOLESCENTS is frequently associated with having risk and protective factors reported to date have drug-using peers). Although the specific mecha- been identified by comparing drug abusers and nisms mediating this influence are not definitely controls on the basis of currently existing charac- known, it is likely that the influence is mediated in teristics or reports of conditions existing prior to part through drug-using peers increasing drug onset of drug use. For example, individuals are availability and providing social reinforcement for divided into drug users and non-drug users on the drug use. Similarly, coming from an impoverished basis of a survey, and compared as to demographic environment is thought to be a risk factor for drug characteristics and other traits. The factors that use because it fails to provide reinforcers as an distinguish the drug users from the non-drug users alternative to drug use. are then identified as risk factors for drug use. GENETIC influences may also underlie many risk This strategy permits the inexpensive identifica- factors for both drug use and dependence. These tion of a large number of possible risk factors for influences may contribute to drug use through per- drug use. The ability of the strategy to detect possi- VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview 1317 ble risk factors is limited only by the selection of One problem that may affect both types of epi- characteristics to be compared. With this strategy, demiological studies is the failure to define risk however, it is sometimes not clear if a characteristic factors operationally or objectively. This occurs less existed prior to onset of drug use or developed as a often when the risk factor involves direct measure- consequence of drug use. Since, moreover, the re- ment of the individual or use of standardized tests ports of the preexisting conditions are often based than when individuals are asked about a trait and on retrospective recall, people’s memory problems no definition or operational criteria for the trait is as well as their attempts to justify their drug use given. For example, if subjects are asked to report may confound the accuracy of the self-reports. Fi- on their current level of self-esteem (i.e., whether it nally, inappropriate control groups are sometimes is low, medium, or high), failure to define the con- employed whose subjects differ from drug users in cept operationally may cause confusion over its important aspects (e.g., demographic and clinical presence or absence in a given individual, and this features), and this confounds the research design. confusion will also increase its variability across Longitudinal Epidemiological Studies. A individuals. better research method for identifying risk and pro- Experimental Laboratory Studies. This tective factors in drug use is the longitudinal study strategy (termed the high-risk design) is aimed at design. With this design, individuals are assessed determining the mechanism by which risk factors for various characteristics prior to the age of risk exert their effects. It compares two groups of indi- for drug abuse and then followed over time to de- viduals who are distinguished by the presence or termine those who do and those who do not become absence of a particular risk factor. For example, the drug users. After drug users have been identified, two groups might consist of children of substance earlier characteristics that distinguished them from abusers and children of non-substance abusers, or nonusers can be determined. individuals who are depressed and individuals who The advantages of this method are that the drug are not depressed. The two groups are then com- users and nonusers are drawn from the same popu- pared on the basis of various dependent measures, lation and therefore constitute appropriate com- which may include baseline characteristics (e.g., parison groups. Furthermore, because the study personality) or response to experimental manipula- design is prospective, it does not rely on the retro- tions (e.g., reaction to stress). If the two groups spective recall of events or conditions that might respond differently on a dependent measure, this have existed prior to the onset of drug use and suggests that the measure is a possible mechanism therefore might be confounded by incorrect mem- by which the trait is related to drug use. ory or other problems. Finally, because this design This strategy has several advantages. Because it provides for initial assessment of the subjects prior entails selecting subjects on the basis of a specific to the onset of drug use, preexisting conditions can characteristic, it affords a high degree of control be separated from the consequences of drug use. over extraneous factors that might confound the This design has not been widely employed, how- interpretation of epidemiological studies. It also ever, owing to the expense and time required to allows researchers to measure subjects’ responses conduct the studies. There is also the problem of directly under standard environmental conditions, sample bias that might occur as a result of the rather than relying on self-reports of past events. In attrition of subjects. For example, drug users with addition, it permits the experimental manipulation severe dependence or psychiatric disorders might of test conditions, which in turn allows the general- be lost in the longitudinal follow-up process, thus ity of an observed effect to be determined. It also leaving only the less severe drug users in the subject enhances the probability that the observed effect is sample. due to the experimental manipulation. Finally, it In general, both cross-sectional and longitudinal permits mechanisms underlying the risk factors to epidemiological strategies are useful in identifying be identified and explored, a process that can only risk factors for drug use and dependence. They are be assessed correlationally through statistical mod- also both useful in increasing the predictive speci- eling in epidemiological studies. ficity of risk factors and in allowing fundamental In contrast to epidemiological strategies, how- features of various risk factors to be identified by ever, the high-risk strategy can only address one use of sophisticated statistical modeling. risk factor per study. It is further restricted by the 1318 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: An Overview appropriateness of criteria used for subject selec- are based on certain assumptions about the nature tion and the experimental measures employed. For of the genetic influence and parental mating char- example, inappropriate subject inclusion criteria acteristics that may affect interpretation of the may exclude the subjects at risk, or inappropriate results. response measures may fail to detect group differ- Animal Studies. Certain factors contributing ences that are present. Laboratory studies also typ- to drug use and dependence can be studied experi- ically employ only a relatively small number of mentally only in animals. For example, it would be subjects. This small number increases the likeli- unethical to make a human being dependent on hood that a biased sample will result, thus making drugs in order to study the process of becoming for reduced generalizability of the findings. drug dependent. In animals, this process can be Genetic Studies. A number of strategies are brought under experimental control and studied di- available to determine if genetic influences are in- rectly. In human beings, drug use or dependence volved in drug use and dependence. Family studies typically becomes evident to researchers only after determine if drug use or dependence ‘‘run in fami- it has occurred, and then the process can be studied lies.’’ If higher rates of drug use are found in the only retrospectively. relatives of drug users than in the relatives of non- A number of strategies are available for studying drug users, then genetic influences may be in- drug taking by animals. The most common of these volved. To separate the effects of genes and envi- are the animal drug self-administration methods. ronment, however, requires doing adoption or twin With these methods, animals are equipped with studies. In adoption studies, evidence of genetic small tubes (catheters) that run directly from the influences is provided by adoptees having higher animal’s bloodstream to an injection pump located rates of drug use if their biological parents were outside the cage. By pressing a lever, the animal drug users than if their biological parents were not automatically activates the injection pump and re- drug users. In twin studies, since identical (mono- ceives a predetermined amount of drug solution zygotic) twins have more of their genes in common injected directly into the bloodstream. Similar than do fraternal (dizygotic) twins, evidence of methods are available to study self-administration genetic influence is suggested by higher concor- of drugs by other routes. By means of these meth- dance rates for drug use or dependence in identical ods, it has been found that animals self-administer than in fraternal twins. Other types of genetic strategies are also avail- essentially the same drugs that humans abuse, and able. The purpose of linkage and association stud- this has resulted in the methods being used to ies is to identify specific genes involved in drug use predict the abuse potential of new drugs before and dependence. In linkage studies, different gen- they are marketed. Keeping drugs with high depen- erations of FAMILIES are examined to determine if a dence potential off the market is also an effective genetic marker is inherited along with a disorder strategy for reducing people’s vulnerability to drug (e.g., substance abuse). In association studies, indi- use and dependence. viduals with and without a disorder are compared Animal drug self-administration methods can to determine the association of the disorder with a also be used to study factors that contribute to a genetic marker. The previously described high-risk person’s acquiring the problem of drug use and study designs are frequently employed in genetic dependence. With these methods, factors thought research. In these studies, subjects who are not yet to influence vulnerability can be experimentally substance abusers are typically divided into two manipulated and studied under controlled labora- groups on the basis of their known risk for sub- tory conditions. As a result of the research, a large stance abuse (e.g., having or not having a family number of factors have been identified with animal history of substance abuse). The two groups are drug self-administration methods that are relevant then compared to identify factors that may contrib- to the development of human drug dependence. ute to their differences in risk for substance abuse. Among these are the reinforcing property of the Most of these genetic strategies have the same drug itself, the speed with which a drug is injected, strengths and limitations previously described in the schedule of drug delivery, the availability of regard to epidemiological and experimental labora- other reinforcers, and the aversiveness of the envi- tory studies. In addition, twin and adoption studies ronment. The knowledge gained from the research VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Gender 1319

can be applied directly to human drug abuse pre- Gender Apart from the use of TOBACCO (ciga- vention efforts. rettes) and PSYCHOACTIVE DRUGS, men show a con- Animal methods make possible the experimental sistently higher rate of drug use than do WOMEN, study of factors that influence the acquiring of the especially with reference to ALCOHOL and to MARI- habit of drug use and dependence, a process that JUANA and other illicit drugs (Substance Abuse and cannot be ethically studied with human beings. An- Mental Health Services Administration, 1992; An- thony, 1991; Robins et al., 1984; Kandel & Yama- imals, however, differ from human beings in many guchi, 1985; Windle, 1990; Robbins, 1989). ways that may be important in the etiology of drug Women are more likely than men to use the drugs abuse, and therefore care must be taken in gener- prescribed by a physician, especially psychotrophic alizing the results of animal studies to human be- drugs (Cafferata et al., 1983), and although men ings. In addition, although animal models provide still have a higher rate of CIGARETTE use, this dif- an excellent way of studying behavioral and envi- ference is decreasing (Kandel & Yamaguchi, 1985; ronmental factors in drug use, the approach cannot National Institute on Drug Abuse, 1989 & 1991; readily be used to study other risk factors (i.e., SAMSA, 1992). psychosocial and cultural influences) that are be- Gender differentiation in society occurs at many lieved to be important in the development of drug levels and in the major institutions such as govern- abuse by human beings. ment, family, the economy, education, and religion, as well as in face-to-face interpersonal interaction (Giele, 1988). It is therefore not surprising that (SEE ALSO: Abuse Liability of Drugs: Testing in drug use behavior differs for men and women. Be- Animals; Addiction: Concepts and Definitions; Ad- cause of the pervasive way in which gender roles junctive Drug Taking; Complications: Mental Dis- affect most aspects of people’s lives, it remains a orders; Conduct Disorder and Drug Use; Disease complex task to understand gender differences in Concept of Alcoholism and Drug Abuse; Epidemiol- patterns of drug use. It is expected that gender will ogy of Drug Abuse; Ethnicity and Drugs; Research, influence patterns of substance use and conse- Animal Model; Wikler’s Pharmacologic Theory of quences of substance abuse, in part because men Drug Addiction) and women are socialized according to different behavior patterns and values. Normative expectations for men include self-reliance and physical ef- BIBLIOGRAPHY fectiveness. By contrast, women are taught to value close relationships and to define themselves in GLANTZ, M., & PICKENS, R. (1992). Vulnerability to drug terms of those relationships. With regard to sub- abuse. Washington, DC: American Psychological As- stance use, the literature shows that gender (a) is sociation. associated with use of alcohol and drugs; (b) is HAWKINS,J.D.,CATALANO, R. F., & MILLER,J.Y. associated with a variety of psychosocial character- (1992). Risk and protective factors for alcohol and istics that are themselves associated with alcohol other drug problems in adolesence and early adult- and drug use; (c) and may be associated with dif- hood: Implications for substance abuse prevention. ferent etiologies of alcohol and drug use—and with Psychological Bulletin, 112, 64–105. different consequences of substance use and treat- KAHN, H. A., & SEMPOS, C. T. (1989). Statistical meth- ment outcomes. The role of gender in drug use has ods in epidemiology. New York: Oxford University been demonstrated in a number of studies con- Press. ducted in the United States; several of these have OFFICE OF SUBSTANCE ABUSE PREVENTION. (1991). Break- provided comprehensive comparisons of the psy- ing new ground for youth at risk: Program sum- chological, social, and biological characteristics of maries. OSAP Technical Report 1, DHHS Publication male and female drug users (Kaplan & Johnson, 1992; Lex, 1991; Gomberg, 1986; Ray and No. (ADM) 91-1658. Washington, DC: U.S. Govern- Braude, 1986). ment Printing Office. According to the convergence hypothesis, the in- ROY W. PICKENS creasing similarity of roles and activities of men DACE S. SVIKIS and women, as illustrated by the increasing partici- 1320 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Gender pation of women in the paid labor force, will result able in men than it is in women (Landrine, in the drug and alcohol behaviors of women in- Bardwell, & Dean, 1988; Lemle & Mishkind, 1989; creasingly approximating those of men (see Adler, Gomberg, 1986). Women are more likely to use 1975; Bell, 1980). Although there is some evidence substances for therapeutic reasons, specifically for that male and female ADOLESCENTS have similar the relief of mental and physical distress, whereas drug-use behaviors, recent epidemiological data in- men are more likely to use drugs for recreation. dicate that alcohol and drug problems are still more Surveys in which it was found that men use more common among men than among women (An- illicit drugs, primarily for recreation, and women thony, 1991). Lennon (1987) found no support for use more psychotherapeutic drugs have borne out the hypothesis that women in ‘‘male’’ jobs resem- this theory. bled men in terms of their levels of drinking. In the A closely related hypothesis that is particularly case of cigarettes, the increasing similarity of men’s relevant to the higher use of psychotropic drugs by and women’s behavior has been the result of both women is that society permits women to perceive women increasing and men decreasing their use of more illness (morbidity) and to use more medical cigarettes. There is little evidence to support the care than it does men, who are expected to be stoic theory of increasing convergence of substance use, in the face of illness. Survey results seem to confirm although it should be noted that many of the early the behavioral differences suggested by this hy- studies of alcohol or drug use included only men, so pothesis. In a review of morbidity and mortality that little is known about trends in women’s use studies, Verbrugge (1985) found that women con- (Robins & Smith, 1980; see Vannicelli & Nash sulted physicians more often than men, assumed [1984] for an analysis of sex bias in alcohol the patient’s role more readily, and appeared to studies). take better care of themselves in general. These The various perspectives that can be used to behaviors would make women more inclined than explain gender differences in drug and alcohol use men to use prescription drugs and less inclined to include: (1) gender role explanations; (2) the social use other drugs. The increasing use of cigarettes by control theory; and (3) biological explanations. Ex- younger women, however, is one behavior that runs planations that draw on gender role theories to counter to this hypothesis. explain male-female differences refer to normative According to the social control theory, those who expectations and rules regarding the behavior of males and females. According to one hypothesis, have strong ties to societal institutions such as fam- there are distinctive gender styles in expressing ily, school, or work are less likely to have a problem pathology (Dohrenwend & Dohrenwend, 1976). with use of substances. This perspective stems from The male style features acting-out behaviors (in- Emile Durkheim’s classic study of SUICIDE (1898). cluding drug and alcohol use), whereas the female Umberson (1987) applied Durkheim’s perspective style involves the internalization of distress. A find- to health behaviors and showed that social ties ing consistent with this hypothesis was that of sev- affect the health behaviors of individuals (e.g., eral researchers, who observed that for females, physical activity, alcohol consumption, compliance conformity to the female identity was related to with doctor’s recommendations, etc.) and that con- higher psychological distress and lower substance sequently they affect health status and mortality use than was observed in males (Horowitz & White, rates. Social ties, according to this argument, affect 1987; Huselid & Cooper, 1992; Snell, Belk, & drug use behaviors in two ways. First, there is an Hawkins, 1987; Koch-Hattem & Denman, 1987). increased likelihood that the behavior of those with The evidence for males has been inconsistent, how- strong social ties will be monitored by family mem- ever. Although there was more alcohol and drug bers and friends, and this would tend to decrease use among males than among females, ascribing to use of illicit or unhealthy substances. Second, the the conventional masculine role did not necessarily responsibility and obligation entailed in an individ- lead to more alcohol or drug problems for males. ual sharing strong ties and frequent activities with A second explanation for gender differences in family and friends make for more self-regulation of alcohol and drug use is that societal expectations behavior. Marriage and being a parent represent differ for men and women, with the result that important social ties that may affect people’s use of using illicit substances for pleasure is more accept- substances, especially in the case of women, be- VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Gender 1321

cause of their traditional roles in nurturing and (SEE ALSO: Comorbidity and Vulnerability; Con- maintaining family relationships. duct Disorder and Drug Use; Epidemiology; Gender Several studies have shown the increased vul- and Complications of Substance Abuse) nerability to drug use of women in relation to social ties. Kaplan and Johnson (1992) showed that the BIBLIOGRAPHY attenuation of interpersonal ties resulting from initial drug use caused women, but not men, to in- ADLER, F. (1975). Sisters in crime. Prospect Heights, IL: crease their drug use. Similarly, Kandel (1984) Woreland. reported that interpersonal factors were more sig- ANTHONY, J. C. (1991). The epidemiology of drug addic- nificant for women than for men in explaining tion. In N. S. Miller (Ed.), Comprehensive handbook marijuana use. Ensminger, Brown, and Kellam of drug and alcohol addiction. New York: Marcel (1982) showed that strong family bonds inhibited Dekker. drug use in female adolescents but not in male BELL, D. S. (1980). Dependence on psychotropic drugs adolescents. and analgesics in men and women. In O. J. Kalant Physiological differences may also be important (Ed.), Alcohol and drug problems in women. New in accounting for gender differences in patterns of York: Plenum. substance use. Mello has (1986) suggested that a BRAUDE, M. C., & LUDFORD, J. P. (1984). Marijuana woman’s use of drugs and alcohol may be influ- effects on the endocrine and reproductive systems: A enced by menstrual cycle phases (Mello, 1986), RAUS review report (NIDA Research Monograph 44). although little evidence exists for this hypothesis. Rockville, MD: National Institute on Drug Abuse. Halbreich et al. (1982) examined the scores on the CAFFERATA, G. L., KASPER, J., & BERNSTEIN, A. (1983, Premenstrual Assessment Form and found that June). Family roles, structure, and stressors in rela- women who increased their marijuana use at the tion to sex differences in obtaining psychotropic premenstruum reported significantly greater drugs. Journal of Health and Social Behavior, 24, DEPRESSION,ANXIETY, mood changes, anger, and 132–143. impaired social functioning than did women whose CORRIGAN, E. M. (1985). Gender differences in alcohol marijuana use decreased or stayed the same. and other drug use. Addictive Behaviors, 10, 313– The relatively low rate of consumption of drugs 317. by women may be related to biological differences DOHRENWEND, B. P., & DOHRENWEND, B. S. (1976). Sex in the ways drugs are cleared from the body in differences in psychiatric disorders. American Journal women versus men. The lower ratio of water to of Sociology, 81, 1447–1454. total body weight in women causes them to metab- DURKHEIM, E. (1898). Suicide: A study in sociology. olize alcohol and drugs differently (Mello, 1986; (J. A. Spaulding & G. Simpson, trans.). New York: Straus, 1984). This and other biological factors Free Press. may cause women to have higher BLOOD-ALCOHOL ENSMINGER, M. E., BROWN, C. H., & KELLAM,S.G. CONCENTRATIONS (BACs) than men at equal dosages (Corrigan, 1985; McCrady, 1988). Drugs that (1982). Sex differences in antecedents of substance are deposited in body fat, such as marijuana, may use among adolescents. Journal of Social Issues, be slower to clear in women than in men because of 38(2), 25–42. the higher ratio of fat in women (Braude & GIELE, J. Z. (1988). Gender and sex roles. In N. J. Ludford, 1984). Smelser (Ed.), Handbook of sociology. Newbury Gender roles are the major roles in human soci- Park, CA: Sage Publications. ety, and they influence almost every aspect of an GOMBERG, E. S. L. (1986). Women: Alcohol and other individual’s life. Despite the evidence for gender drugs. In Drugs and society. Binghamton, NY: differences in patterns of drug use, little attention Haworth Press. has been given either to the potential strategic ad- HALBREICH, U., ENDICOTT, J., SCHACHT, S., & NEE,J. vantages that this observation presents for fur- (1982). The diversity of premenstrual changes as re- thering our understanding of drug and alcohol use flected in the Premenstrual Assessment Form. Acta patterns in males and females, or for determining Psychiatrica, 65, 46–65. how prevention and treatment programs might be HOROWITZ,A.V.,&WHITE, H. R. (1987, June). Gender redesigned. role orientations and styles of pathology among ado- 1322 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Genetics

lescents. Journal of Health and Social Behavior, 28, RAY, B. A., & BRAUDE,M.C.(EDS.). (1986). Women and 158–170. drugs: A new era for research (NIDA Research Mono- HUSELID, R. F., & COOPER, M. L. (1992). Gender roles as graph No. 65, DHHS Publication No. ADM 86-1447). mediators of sex differences in adolescent alcohol use Washington, DC: U.S. Government Printing Office. and abuse. Journal of Health and Social Behavior, 33, ROBBINS, C. (1989, March). Sex differences in psychoso- 348–362. cial consequences of alcohol and drug abuse. Journal KANDEL, D. B. (1984). Marijuana users in young adult- of Health and Social Behavior, 30, 117–130. hood. Archives of General Psychiatry, 41, 200–209. ROBINS,L.N.,&SMITH, E. M. (1980). Longitudinal KANDEL, D. B., & YAMAGUCHI, K. (1985). Developmental studies of alcohol and drug problems: Sex differences. patterns of the use of legal, illegal, and medically In O. J. Kalant (Ed.), Alcohol and drug problems in prescribed psychotropic drugs from adolescence to women: Research advances in alcohol and drug prob- young adulthood. In Etiology of drug abuse: Implica- lems (Vol. 5). New York: Plenum. tions for prevention (NIDA Research Monograph Se- ROBINS, L. N., ETAL . (1984). Lifetime prevalence of spe- ries No. 56, DHHS Publication No. ADH 85-1335). cific psychiatric disorder in three sites. Archives of Washington, DC: U.S. Government Printing Office. General Psychiatry, 41, 929–958. KAPLAN, H. B., & JOHNSON, R. J. (1992). Relationships SNELL, W. E., JR., BELK, S. S., & HAWKINS, R. C., II. between circumstances surrounding initial illicit drug (1987). Alcohol and drug use in stressful times: The use and escalation of drug use: Moderating effects of influence of the masculine role and sex-related per- gender and early adolescent experiences. In M. Glantz sonality attributes. SexRoles, 16 , 359–373. & R. Pickens (Eds.), Vulnerability to drug abuse. STRAUS, R. (1984). The need to drink too much. Journal Washington, DC: American Psychological Associa- of Drug Issues, 14, 125–136. tion. SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES KOCH-HATTEM, A., & DENMAN, D. (1987). Factors asso- ADMINISTRATION. (1993). National Household Survey ciated with young adult alcohol abuse. Alcohol and on Drug Abuse: Population estimates 1992. Washing- Alcoholism, 22, 181–192. ton, DC: U.S. Department of Health and Human Ser- LANDRINE, H., BARDWELL, S., & DEAN, T. (1988). Gender vices, Public Health Service. expectations for alcohol use: A study of the signifi- UMBERSON, D. (1987). Family status and health behav- cance of the masculine role. SexRoles, 19 , 703–712. iors: Social control as a dimension of social integra- LEMLE, R., & MISHKIND, M. E. (1989). Alcohol and mas- tion. Journal of Health and Social Behavior, 28, 306– culinity. Journal of Substance Abuse Treatment, 6, 319. 213–222. VANNICELLI, M., & NASH, L. (1984). Effect of sex bias on women’s studies on alcoholism. Alcohol Clinical and LENNON, M. C. (1987). Sex differences in distress: The impact of gender and work roles. Journal of Health Experimental Research, 8, 334–336. and Social Behavior, 28, 290–305. VERBRUGGE, L. M. (1985, September). Gender and health: An update on hypotheses and evidence. Jour- LEX, B. W. (1991). Gender differences and substance abuse. In N. K. Mello (Ed.), Advances in substance nal of Health and Social Behavior, 26, 156–182. WINDLE, M. (1990). A longitudinal study of antisocial abuse (Vol. 4). London: Jessica Kingsley. behaviors in early adolescence as predictors of late MCCRADY, B. S. (1988). Alcoholism. In E. A. Blechman adolescence substance use: Gender and ethnic group & K. O. Brownell (Eds.), Handbook of behavioral differences. Journal of Abnormal Psychology, 99(1), medicine for women. New York: Pergamon. 86–91. NATIONAL INSTITUTE ON DRUG ABUSE. (1991). National Household Survey on Drug Abuse: Main Findings MARGARET E. ENSMINGER 1990. Washington, DC: U.S. Department of Health JENNEAN EVERETT and Human Services, Public Service, Alcohol, Drug Abuse, and Mental Health Administration. NATIONAL INSTITUTE ON DRUG ABUSE. (1989). National Genetics Genes are passed from parent to Household Survey on Drug Abuse: Highlights 1988. child in the process of sexual reproduction. These Washington, DC: U.S. Department of Health and Hu- genes determine some of the features of the individ- man Services, Public Service, Alcohol, Drug Abuse, ual and contribute directly and indirectly to many and Mental Health Administration. more. The possibility of genetic influences in sub- VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Genetics 1323 stance abuse has received considerable attention. posite-sex alcoholic relatives as do men, and this Evidence that genetic influences may be involved suggests that there is no differential heritability comes from family studies, where substance abuse related to gender. has been found to run in families. For example, Although less frequently studied, genetic influ- alcoholics have been found to have more relatives ences for other forms of drug use and dependence who are alcoholic than would be expected from the have also been shown, but only males have typi- base rate for ALCOHOLISM in the general popula- cally been studied in this context. Heritabilities tion. Similarly, higher rates of HEROIN and CO- reported for tobacco smoking range from 0.28 to CAINE abuse are also seen in the relatives of heroin 0.84 and are not affected by other factors that may and cocaine abusers than occur in the general pop- contribute to differences in concordance rates in ulation. twins. Heritabilities reported for other types of il- Both twin and family studies have been con- licit drug use (but not necessarily drug depen- ducted to separate genetic from environmental in- dence) range from 0.4 to 0.6. Heritability for any fluences in the familial transmission of substance substance abuse or dependence (excluding alcohol abuse. Most of the research has involved ALCOHOL. and tobacco) in alcoholic probands is 0.31. There is general agreement that genetic influences Linkage and association studies permit the iden- are involved in both alcohol use and alcoholism, at tification of specific genes involved in substance least for males. Twin studies of males from the abuse. In linkage studies, different generations of general population have found that if one pair families are examined to determine if a genetic member drinks alcohol, the other pair member is marker is inherited along with a disorder (e.g., more likely to drink (i.e., they are concordant for substance abuse). In association studies, individu- this behavior) if the two members shared all the als with and without a disorder are compared to same genes (if they are monozygotic or identical determine the association of the disorder with a twins) than if they share only about half of their genetic marker. To date, no specific gene for alco- genes (if they are dizygotic or fraternal twins). holism or for other types of drug dependence has Similar studies on clinical patients have found been identified. higher concordance for alcoholism among men who Animal models have also been employed to are monozygotic rather than dizygotic twins. Adop- study genetic influences in substance abuse. Evi- tion studies have found that sons of alcoholic bio- dence of significant genetic influence has been logical parents were more likely to be alcoholic as found in the characteristics of many drug responses adults than sons of nonalcoholic biological parents, relevant to drug abuse (e.g., drug preference), and when both groups were adopted out early in life chromosomal loci have been identified that mediate and raised by nonalcoholic adoptive parents. at least some of these effects. To the extent that the Among men, estimates of the proportion of vari- genetic structure of mice is similar to that of human ance in alcohol-dependence liability due to genetic beings, the findings derived from animal models influences (i.e., heritability) range from 0.50 to suggest testable hypotheses to be explored in hu- 0.60, depending on the subject population and sub- man-association studies. In strains of rats that were type of alcoholism. bred in laboratories to study their preference for For women, the role of genetic factors in alcohol alcohol, the strain that developed a strong prefer- use and alcoholism is less convincing. This is pri- ence for alcohol had lower brain levels of the marily because women have been studied less often NEUROTRANSMITTER serotonin compared to the than men and in smaller numbers. One reason for strain that did not prefer alcohol. This is of interest this discrepancy is that women are less likely to because alterations in SEROTONIN neurotrans- have alcohol problems, and this fact itself may mission have also been noted in studies of impul- reflect the greater role of nongenetic influences for sive aggressive human males (who have a higher women. In twin and adoption studies involving likelihood of developing alcohol or drug problems) women, evidence of genetic influence has been compared to human males without those behav- found less consistently than has been found for iorial traits. men, with heritabilities for women ranging from 0.00 to 0.56. depending on the study. Nevertheless, (SEE ALSO: Attention Deficit Disorder; Causes of women have similar percentages of same- and op- Substance Abuse; Conduct Disorder and Drug Use; 1324 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Psychoanalytic Perspective

Disease Concept of Alcoholism and Drug Addiction; other drugs. It tells the child that this is acceptable Epidemiology of Drug Abuse) behavior, particularly if the surrounding social culture echoes that opinion. Cultures and subcultures BIBLIOGRAPHY that traditionally control drinking generally produce people who drink in a controlled way; cultures GLANTZ, M., & PICKENS, R. (1992). Vulnerability to drug and subcultures that condone excess also reproduce abuse. Washington, DC: American Psychological As- themselves. sociation. It is important to remember, however, that even HAWKINS,J.D.,CATALANO, R. F., & MILLER,J.Y. those with a strong genetic loading for alcoholism (1992). Risk and protective factors for alcohol and can only become a ‘‘practicing’’ alcoholic if they other drug problems in adolesence and early adult- have alcohol available. Despite its many problems, hood: Implications for substance abuse prevention. Prohibition (1920–1933) reduced the number of Psychological Bulletin, 112, 64–105. alcoholics; successful interdiction of drugs would KAHN, H. A., & SEMPOS, C. T. (1989). Statistical meth- reduce the number of substance abusers. However, ods in epidemiology. New York: Oxford University growing up in an area where drugs are freely avail- Press. able increases the likelihood of trying them and— OFFICE OF SUBSTANCE ABUSE PREVENTION. (1991). Break- assuming community complacence or peer ap- ing new ground for youth at risk: Program sum- proval and encouragement—of continuing to take maries. DHHS Publication No. (ADM) 91-1658. them. For example, during the war in VIETNAM, Washington, DC: U.S. Government Printing Office. many U.S. soldiers who had not been OPIATE ad- DACE S. SVIKIS dicts found themselves in the war zone, exposed to ROY W. PICKENS STRESS and personal danger, and surrounded by cheap available HEROIN in a context that condoned its use. Many became addicted. On their return home, however, almost all gave up their drug use Psychoanalytic Perspective Increased with relative ease. vulnerability to ALCOHOL and drugs is related to We also know that the person one is—the kind the coming together of a number of influences, each of personality one has—also plays a role in one’s of which is itself of varying strength. Our biologies, susceptibility to using and misusing drugs. A num- our individual social and cultural settings and ber of studies suggest that maladjustment precedes backgrounds, our personal idiosyncratic life expe- the use of illicit drugs; the closer one is in style to an riences, and the persons we become as a result of all Eagle Boy Scout, the less likely one is to use drugs. these may contribute to the likelihood of our using Rebelliousness, stress on independence, apathy, drugs—and then of our continuing to use them. We pessimism, DEPRESSION, low self-esteem, and low are neither vulnerable nor invulnerable to using academic aspirations and motivation make the use drugs or alcohol, nor to using them to excess; vul- of illicit drugs more likely. Delinquent and deviant nerability is a continuum, ranging from least to behavior come before the drug use; they are not the most vulnerable. Under the right, or the wrong, result of it. circumstances, many of us will use drugs. ALCOHOLISM runs in families; if an individual’s (SEE ALSO: Causes of Substance Abuse: Psychologi- parent, grandparent, or sibling is alcoholic, that cal (Psychoanalytic) Perspective; Conduct Disorder individual’s own risk is significantly increased. It and Drug Use; Families and Drug Use; Religion seems certain that an important contributor to this and Drug Use) in many families is GENETIC. While we find a similar increase in the frequency of substance abuse in BIBLIOGRAPHY the children of parents who use all sorts of drugs, we do not yet have evidence that this too is genetic. BOHMAN, M., SIGVARDSSON, S., & CLONINGER,C.R. Certainly, another contributor to this familial pat- (1981). Maternal inheritance of alcohol abuse. Ar- tern is the exposure that a developing child has to chives of General Psychiatry, 38, 965–969. the sight and experience of a parent or other impor- CHEIN, I., ETAL . (1964). The road to H: Narcotics, delin- tant figure in the environment using alcohol and/or quency, and social policy. New York: Basic Books. VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Race 1325

CLONINGER, C. R., BOHMAN, M., & SIGVARDSSON,S. rate among Hispanic women. Overall, white men (1981). Inheritance of alcohol abuse. Archives of Gen- had the highest rate of illicit drug use compared to eral Psychiatry, 38, 861–868. the other two groups, with the most prominent dif- WILLIAM A. FROSCH ference seen in the 18 to 29 age group. The lifetime prevalence of drug dependence followed the pattern of drug use in the three groups, but there were few differences in the rates for active dependence. Race Despite reservations about the use of Another major source of estimates on racial/eth- race and ethnicity in health research (e.g., Bhopal nic differences in drug use and dependence is the & Donaldson, 1998; LaVeist, 1994; Williams et al., National Comorbidity Survey. Data from the NCS 1994), this variable remains one of the most often agree with estimates from the other household sur- reported socio-demographic characteristics in drug veys. Blacks and Hispanic are less likely to use abuse/dependence studies. drugs than Whites but Blacks do not differ from Data from the Monitoring the Future Study Whites in the probability of becoming dependent (Johnston, O’Malley & Bachman, 1996) and the on drugs. What distinguishes the groups is persis- Youth Risk Behavior Survey (Centers for Disease tence in drug dependence once the problem has Control, 1995) are consistent in showing that black started (Kessler et al., 1995). Blacks are 3 times adolescents are less likely to use most drugs than and Hispanics 2.4 times more likely to report past their white and Hispanic counterparts. The Na- year dependence on drugs than their white counter- tional Household Survey on Drug Abuse, which in- parts. In other words, while African Americans are cludes adult participants and adolescents who are less likely to initiate drug use and equally likely to not in school, shows that after the age of 25 years, become dependent, they are more likely than African Americans report more illicit drug use than Whites to remain dependent. Whites (SAMHSA, 1999). In 1998, among persons There is growing evidence that these racial/eth- 35 years and older, 4.8 percent of blacks versus 3.2 nic differences in drug use and drug dependence percent of whites had used an illicit drug in the past are not due to innate racial differences. For exam- month, and 1.3 percent versus 0.3 percent had ple, Crum and Anthony (2000) have shown that, used cocaine, respectively. Blacks had lower rates when socio-economic factors (e.g., poverty and of past month alcohol use, ‘‘binge’’ drinking, and neighborhood characteristics) are taken into con- heavy alcohol use than whites and Hispanics sideration, race/ethnicity becomes and insignifi- (SAMHSA, 1998). cant influence. Other factors that may help account Data from other large-scale surveys have been for observed racial/ethnic differences in the vulner- used to estimate drug use and dependence in differ- ability to drug use and dependence are dropping ent groups. The Epidemiologic Catchment Area out of school (Obot & Anthony, 2000), opportunity (ECA) Study, a prospective study of drug depen- to use illegal drugs (SAMHSA, 1998), and percep- dence in the United States, show that black youth tion of risks associated with drug use (Ma & Shive, are less likely than white youth to initiate licit and 2000). illicit drug use (Helzer, Burnam & McEvoy, 1991). This is reflected in the rate of lifetime alcoholism among black males in the 18 to 29 age group when BIBLIOGRAPHY compared to whites, 12.7 percent versus 28.3 per- ANTHONY, J. C., & HELZER, J. E. (1991). Syndromes of cent. With increase in age, rates for blacks exceed drug abuse and dependence. In L.N. Robins & D.A. those of whites and Hispanics until at 65 and over, Regier (eds.), Psychiatric disorders in America: the blacks are nearly twice as likely as whites to be Epidemiologic Catchment Area Study (pp. 116-154). alcohol dependent. The ECA data also show that New York: The Free Press. young Hispanic men have about the same level of BHOPAL,R.&DONALDSON, L. (1998). White, European, risk of developing alcoholism as Whites. Western, Caucasian, or What? Inappropriate labeling In a separate analysis of data from the ECA, in research on race, ethnicity, and health. American Anthony & Helzer (1991) found that the rate of Journal of Public Health, 88(9), 1303-1307. illicit drug use for Hispanic men was much lower CENTERS FOR DISEASE CONTROL AND PREVENTION (1995). that those for blacks and whites, with the lowest Youth Risk Behavior Survey, 1995. Atlanta: CDC. 1326 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Sensation Seeking

CRUM, R. M., & ANTHONY, J. C. (2000). Educational level unsafe sex, disinhibited partying, reckless driving, and risk for alcohol abuse and dependence: differ- and criminal activities. ences by race-ethnicity. Ethnicity and Disease, 10(1), Sensation seeking has been assessed most often 39-52. using the Sensation Seeking Scale which contains HELZER,J.E.&BURNAM, A., & MCELVOY, L. T. (1991). four subscales: Thrill and Adventure Seeking, Ex- Alcohol abuse and dependence. In L.N. Robins & D.A. perience Seeking, Disinhibition, and Boredom Sus- Regier (eds.), Psychiatric disorders in America: the ceptibility. The last three of these are most related Epidemiologic Catchment Area Study (pp. 81-115). to drug use. A total score is obtained by summing New York: The Free Press. the four subscales. A newer scale is called Impulsive JOHNSTON, L. D., O’MALLEY, P. M., & BACHMAN,J.G. Sensation Seeking because it combines sensation- (1996). National survey results on drug use from the seeking items with those of a closely related trait, Monitoring the Future Survey, 1975–1995. Vol.1. impulsiveness. Secondary school students. Rockville, MD: National Many studies have shown that sensation seeking Institute on Drug Abuse. is related to current heavy alcohol use and illegal OBOT,I.S&ANTHONY, J. C. (2000). School dropout and drug use among adolescents and young adults, and injecting drug use in a national sample of white non- other studies (Bates et al., Cloninger et al., Hispanic American adults. Journal of Drug Educa- Teichman et al.) have demonstrated that sensation tion, 30(2), 145–155. seeking at pre- or early adolescence predicts later alcohol and drug use during early adulthood. Lewis MARGARET E. ENSMINGER Donohew and his colleagues have designed com- SION KIM munications for antidrug campaigns based on the JENNEAN EVERETT sensation seeking traits of those at risk for use and REVISED BY ISIDORE S. OBOT abuse of drugs. The general tenor of these advertisements is that there are healthier ways to seek stimulation than through drugs. The style of the Sensation Seeking Sensation seeking is a presentations as well as the content is aimed at high personality trait most recently defined by its origi- sensation seekers. nator, Zuckerman (1994), as ‘‘the seeking of var- This writer’s experience with treatment of drug ied, novel, complex, and intense sensations and abusers in a therapeutic community suggested that experiences, and the willingness to take physical, the trait is an important consideration in predicting social, legal, and financial risks for the sake of such outcome in combination with other traits and envi- experience.’’ ALCOHOL and DRUG abuse and GAM- ronmental considerations. Drug abusers who were BLING represent expressions of the needs involved in also high sensation seekers had a special suscepti- this trait, and over thirty years of research have bility to boredom. What can substitute for the kind shown that this trait is central to the initial attrac- of exciting lives they led as part of the drug scene? tion to drugs and the tendency to engage in social or If they cannot obtain an interesting job, providing abusive use of them. Among drug users, high sensa- varied kinds of stimulation, or if they cannot find tion seekers are likely to use more kinds of drugs exciting friends like those still involved with drugs, than moderate sensation seekers (varied experi- they soon turn to drugs themselves. Therapists ence), to use psychedelic drugs (novelty), and stim- sometime assume that drugs were used to deal with ulants (intensity). However, they also use depres- ANXIETY and DEPRESSION, or as ‘‘self-medication.’’ sants like OPIATE drugs for the sake of the highs of This only happens in a minority of cases. Early the ‘‘rush’’ and the sensations of the subsequent substance abuse is primarily driven by sensation depressant phase. seeking and impulsivity, not by neurotic needs. Drug users rate higher in sensation seeking than Anxiety and depression usually emerge as a reac- users of alcohol, only showing their willingness to tion to drugs or their WITHDRAWAL and to the take the extra risks associated with the use of illegal stresses of drug-life and quickly subside when the substances. Sensation seeking is involved in many user is in effective treatment setting or abstinent other kinds of interests and activities related to after DETOXIFICATION. When bored and frustrated alcohol and drug use including smoking, illicit or in attempts to find interesting work, or working at a VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Sexual and Physical Abuse 1327 monotonous job, the high sensation seeker is most assaulted every year. Data from a 1991 telephone vulnerable to relapse. national survey of women indicate that about 20 per 100 (20%) of the sample reported one or more (SEE ALSO: Adolescents and Drug Use; Conduct childhood sexual-abuse experiences (Wilsnack et Disorder and Drug Use; Prevention) al., 1994). Few research studies have focused specifically on the question of whether children who BIBLIOGRAPHY are physically and sexually abused are at increased risk of substance abuse. Dembo et al. (1988) sug- BATES, M. E., LABOURIE, E. W., & WHITE, H. R. (1985). gest three reasons why child abuse has not been A longitudinal study of sensation seeking needs and included in the conceptual schemes examining the drug use. Paper presented at the 93rd Annual Con- process by which youths become involved in drug vention of the American Psychological Association, use. First, CHILD ABUSE has only recently (in the Los Angeles, CA, August 23–27. 1980s) surfaced as an issue receiving research and CLONINER, C. R., SIGVARDSSON, S., & BOHMAN,M. policy attention. Second, both child-abuse experi- (1988). Childhood personality predicts alcohol abuse ences and illicit drug use are often hidden phenom- in young adults. Alcoholism: Clinical and Experimen- ena, so that any covariation in their occurrence is tal Research, 12, 494–505. difficult to observe. Third, the focus on social- DONOHEW, L., LORCH, E. P., & PALMGREEN, P. (1998). psychological and socio-cultural factors left little Applications of a theoretic model of information expo- opportunity for child-abuse variations to be consid- sure to health interventions. Human Communications ered. Throughout the 1980s and into the 1990s, Research, 24, 454–468. there has been increasing recognition of the poten- TEICHMAN, M., BARNEA, Z., & RAHAV, G. (1989). Person- tial importance of abuse to the child’s and adoles- ality and substance abuse: A longitudinal study. Brit- cent’s emotional development and the potential ish Journal of Addication, 84, 181–190. connection to substance use and other problem be- ZUCKERMAN, M. (1979). Sensation seeking: Beyond the haviors (Widom, 1991; Zingraff et al., 1993). The optimal level of arousal. Hillsdale, NJ: Erlbaum. central hypothesis guiding research is that physi- ZUCKERMAN, M. (1983). Sensation seeking: The initial cally and sexually abused children and adolescents motive for drug abuse. In E. Gotheil et al. (Eds.), may use illicit drugs to help cope with the emo- Etiological aspects of alcohol and drug abuse (pp. tional difficulties caused by their negative self-per- 202–220). Springfield, IL: Charles C. Thomas Pub- ceptions or other internal difficulties that result lishers. from the abuse (Cavaiola & Schiff, 1989; Singer, ZUCKERMAN, M. (1987). Is sensation seeking a predispos- Petchers, & Hussey, 1989; Dembo et al., 1988). ing trait for alcoholism? In E. Gottheil, et al. (Eds.), Much existing research has concentrated on Stress and addiction (pp. 283-301). New York: cohorts of adolescents. The rationale for the vulner- Bruner/Mazel. ability of childhood victims of abuse to drug depen- ZUCKERMAN, M. (1994). Behavioral expressions and dence in adolescence includes first, the ramifica- biosocial bases of sensation seeking. New York: Cam- tions of abuse for lowering self-image and self- bridge University Press. esteem, while increasing self-hatred. Based on MARVIN ZUCKERMAN Kaplan, Martin, and Robbins’ (1984) proposition that self-derogation leads to drug use, this model suggests that the abuse of children is related to Sexual and Physical Abuse An increased illicit drug use, both directly and as mediated by recognition of the experience of physical and sexual self-derogation (Dembo et al., 1988). Second, abuse in the lives of many children and ADOLES- drugs may provide emotional or psychological es- CENTS has led to the increased interest in the impact cape and self-medication for young abuse victims; of such abuse on drug use (Cavaiola & Schiff, they may turn to drugs to chemically induce for- 1989; Straus & Gelles, 1990; Dembo et al., 1988). getting or to cope with feelings of ANXIETY (Miller, In their 1985 survey of over 6,000 families in the 1990). Third, drug use may provide abused chil- United States, Straus and Gelles (1990) report that dren or adolescents with a peer group, in the form 23 per 1,000 children (2.3%) are seriously of a drug culture, hence reducing feelings of isola- 1328 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Sexual and Physical Abuse

(3018 ס tion and loneliness (Singer, Petchers, & Hussey, nonabused females. In a large sample (N 1989; Widom, 1991). of Alabama 8th and 10th graders, Nagy et al. Methodological limitations have prevented the (1994) found that about 10 percent (13% of fe- existing research from giving a definitive answer. males and 7% of males) of the students reported According to Widom (1991), most studies of the being sexually abused. Sexual abuse was defined to association between illicit drug use and childhood include one or more episodes of forced intercourse. victimization have focused on sexually or physi- Both sexually abused males and sexually abused cally abused children in clinical or institutional females reported a higher use of illegal drugs in the settings, making it difficult to generalize to other past month than those students who did not report populations; the studies are often cross-sectional in sexual abuse. While the associations were strong, design, include only retrospective information the analyses did not attempt to control for about childhood-abuse experiences, and do not uti- confounding variables and were cross-sectional lize control groups. Therefore, the validity and reli- rather than longitudinal, so that causality cannot ability of these data have been criticized. Since be inferred. abuse-related consequences can vary across the life Wilsnack et al. (1994), using a national sample span, cross-sectional studies may miss important of adult women, examined the abuse of alcohol and ramifications of abuse and it may be impossible to drugs by women who reported retrospectively on determine the developmental-causal sequence whether they had been sexually abused as children. (Briere, 1992; Dembo et al., 1988). Furthermore, They found strong positive associations between most of the studies do not control for other child- being abused sexually as a child and six different hood characteristics that may mediate the effects of measures of drinking behaviors and two summary abuse. Studies focusing on the abuse victims as drug-use measures. While these analyses are con- adults run further methodological risks. When sidered preliminary by the authors, because they do asked about abuse from their childhood, these not attempt to control for confounding variables, adults may forget, redefine events in terms of the the findings do suggest that early sexual trauma present, or repress certain thoughts and events. may be an important risk factor for substance In one of the earliest reviews of the impact of abuse later in life. sexual abuse in childhood, Browne and Finkelhor In a retrospective study, Miller (1990) compared (1986) reported that adult WOMEN victimized as forty-five alcoholic women with forty women cho- children were more likely to manifest DEPRESSION, sen randomly from the same community. The rela- self-destructive behavior, anxiety, feelings of isola- tionships between child abuse by the father and the tion, poor self-esteem, and substance abuse than development of alcoholism was examined by con- their nonvictimized counterparts. They distin- trolling on the parents’ alcohol problems, family guished initial effects—identified as the manifesta- structure during childhood, income source, and tions within two years of termination of abuse— age. Higher levels of negative verbal interaction from long-term effects. and higher levels of moderate and serious violence In a carefully designed study, Widom (1992) were both predictive of those who were found in the followed two groups in arrest records for fifteen to alcoholic group. twenty years. One group of 908 individuals with In their review and synthesis of empirical studies court-substantiated cases of childhood abuse or ne- regarding the impact of sexual abuse on children, glect was matched according to sex, age, race, and Kendall-Tackett, Williams, and Finkelhor (1993) socioeconomic status with a comparison group of found that poor self-esteem was a frequently occur- 667 children not officially recorded as abused or ring consequence of sexual abuse. They also con- neglected. As indicated by arrest records, the be- clude that substance abuse, while being a common havior of those who had been abused or neglected behavior for sexually abused adolescents, is not an was worse than those with no reported abuse— inevitable outcome. In a residential treatment cen- abused or neglected children were more likely to be ter, Cavaiola and Schiff compared with two control arrested as juveniles, as adults, and for a violent groups the self-esteem of 150 physically or sexually CRIME. With regard to drug use, as adults, the abused, chemically dependent adolescents. The re- abused and neglected females were more likely to sults showed that abused chemically dependent ad- be arrested for drug offenses compared to the olescents had lower self-esteem than the two com- VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Sexual and Physical Abuse 1329

parison groups; they found negligible difference BIBLIOGRAPHY between those who had been sexually abused and BRIERE, J. (1992). Methodological issues in the study of those who had been physically abused. sexual abuse effects. Journal of Consulting and Clini- In two populations of youths studied in a juve- cal Psychology, 60, 196–203. nile detention center, Dembo et al. (1988, 1989) BROWNE, A., & FINKELHOR, D. (1986). Impact of child compared the lifetime drug use between detainees sexual abuse: A review of the research. Psychological and a comparable age group in an adjacent county. Bulletin, 99(1), 66–77. The studies showed that the detainees’ sexual vic- CAVAIOLA, A. A., & SCHIFF, M. (1989). Self-esteem in timization and their physical-abuse experiences re- abused chemically dependent adolescents. Child lated significantly to their lifetime use of illicit Abuse and Neglect, 13, 327–334. drugs. Sexual victimization had a direct effect on DEMBO, R., ETAL . (1989). Physical abuse, sexual victim- the frequency of lifetime drug use, whereas physi- ization, and illicit drug use: Replication of a structural cal abuse had both a direct and an indirect effect on analysis among a new sample of high-risk youths. drug use, mediated by the adolescents’ feelings of Violence and Victims, 4(2), 121–138. self-derogation. These findings were based on mul- DEMBO, R., ETAL . (1988). The relationship between tiple-regression analyses that included family physical and sexual abuse and tobacco, alcohol, and background, other risks for drug use, race, and sex. illicit drug use among youths in a juvenile detention center. The International Journal of the Addictions, 23(4), 351–378. CONCLUSION KAPLAN, H. B., MARTIN, S. S., & ROBBINS, C. (1984). Despite methodological issues, the body of avail- Pathways to adolescent drug use: Self-derogation, peer influence, weakening of social controls, and early able evidence suggests that involvement in sub- substance use. Journal of Health and Social Behavior, stance use as an adolescent or adult is linked to an 25, 270–289. increased likelihood of having experienced physical KENDALL-TACKETT, K., WILLIAMS, L. M., & FINKELHOR, or sexual abuse as a child. Owing to limitations in D. (1993). Impact of sexual abuse on children: A re- the retrospective, cross-sectional, and correlational view and synthesis of recent empirical studies. Psy- designs of the research, causal linkages cannot be chological Bulletin, 113(1), 164–180. definitively attributed, and as Briere (1992) notes, KINGERY, P. M., PRUITT, B. E., & HURLEY, R. S. (1992). while much of the existing research is flawed in its Violence and illegal drug use among adolescents: Evi- design, it has set the stage for the development of dence from the U.S. National Adolescent Student more tightly controlled and methodologically so- Health Survey. The International Journal of the Ad- phisticated studies that will be able to better disen- dictions, 27(12), 1445–1463. tangle the antecedents, correlates, and impacts of MILLER, B. A. (1990). The interrelationship between al- sexual and physical abuse. cohol and drugs and family violence. NIDA Research Further research is needed to examine questions Monograph, No. 103. Rockville, MD: National Insti- in which our knowledge is meager. First, are there tute on Drug Abuse. different effects from physical abuse, sexual abuse, NAGY, S., ADCOCK,A.G.,&NAGY, M. C. (1994). A com- or neglect on substance use or dependence? Do parison of risky health behaviors of sexually active, other psychosocial factors lead to substance abuse? sexually abused, and abstaining adolescents. Pediat- rics, 93(4), 570–575. Second, does the perpetrator of the abuse matter STRAUS, M. A., & GELLES,R.J.(EDS.). (1990). Physical for the impact? Third, does continuity or duration violence in American families. New Brunswick, NJ: of the abuse matter? Fourth, and perhaps most Transaction. important, what are the links between suffering SINGER, M. I., PETCHERS,M.K.,&HUSSEY, D. (1989). maltreatment as a child and later alcohol or drug The relationship between sexual abuse and substance problems? abuse among psychiatrically hospitalized adolescents. Child Abuse and Neglect, 13, 319–325. (SEE ALSO: Families and Drug Use; Family Violence WIDOM, C. S. (1991). ‘‘Childhood victimization and ado- and Substance Abuse) lescent problem behaviors.’’ Paper for the National 1330 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Stress

Institute of Child Health and Human Development bility and predictability aspects of the event. The conference on ‘‘Adolescent Problems and Risk-taking extent to which an event is predictable (i.e., the Behaviors.’’ April 13–16, Berkeley Springs, WV. individual is aware of an upcoming stressful event WIDOM, C. S. (1992). The cycle of violence. Washington, and can prepare for it) and controllable (i.e., the DC: National Institute of Justice Research in Brief: 1– individual perceives the situation as one that he/she 6, October. can control and adapt to) is significantly associated WILSNACK, S. C., ETAL . (1994). ‘‘Childhood sexual abuse with the magnitude of the biological stress response and women’s substance abuse: National survey find- and the negative emotional state associated with ings.’’ Paper for the American Psychological Associa- the event (Frankenhauser, 1980; Hennessey & tion conference on ‘‘Psychosocial and Behavioral Fac- Levine, 1979). Thus, greater the unpredictability tors in Women’s Health: Creating an Agenda for the and uncontrollability, greater the emotional dis- 21st Century.’’ May 12–14, Washington, DC. tress and the biological response associated with ZINGRAFF,M.T.,ETAL . (1993). Child maltreatment and the event. youthful problem behavior. Criminology, 31(2), The aversive quality of stressful situations moti- 173–202. vate individuals to reduce the stress by using a MARGARET E. ENSMINGER variety of coping strategies. Lazarus (1966) identi- COLLEEN J. YOO fied two primary classes of coping: (1) direct action, which is usually behavioral and involves activity aimed at altering the source of stress or one’s relationship to it, and (2) palliation, focused on Stress The term ‘‘stress’’ is frequently defined managing one’s emotional responses rather than as a process involving perception, interpretation, causes of stress. Palliative coping may be behav- response and adaptation to harmful, threatening, ioral or cognitive; it may include denial, with- or challenging events (Lazarus & Folkman, 1984). drawal, taking drugs, and/or other forms of mak- This kind of conceptualization allows the separate ing oneself feel better (or less bad). Direct action is consideration of (1) the events that cause stress a manipulative response aimed at changing a stres- (stressors or stressful life events), (2) the cognitive sor, while palliation is generally accommodative. processes that evaluate stress and the availability of Similar to the above categories are the two types of resources to cope with the stressor (appraisal), coping identified by Lazarus & Folkman (1984). (3) the biological arousal and adaptation associ- These are ‘problem-focussed’ coping aimed at do- ated with the stressor, and (4) behavioral and cog- ing something to alter the source of the stress, and nitive response to the stressful event (actual ‘emotion-focussed’ coping aimed at managing the coping). While different models of stress put more emotional distress associated with the stressful or less emphasis on appraisal mechanisms or bio- event. How people cope with stressful events is key logical adaptation mechanisms, the concept of an to their success in reducing the associated distress organism responding to substantial threat or dan- and producing an effective adaptive response to ger is basic to most theories of stress (e.g., Cohen et similar stressful situations in the future. al., 1986; Mason, 1975; Selye, 1976; Hennessy & Levine, 1979). STRESS AND INCREASED Stress produces a negative emotional state asso- VULNERABILITY TO DRUG USE ciated with perception and appraisal of the stressor, its situational and psychological characteristics, Most major theoretical models of addiction con- and the assessment of resources available for ceptualize stress as an important factor in the moti- coping. Stress also activates a biological response vation to use addictive substances. For example, with sympathetic arousal, activation of the pitu- the Stress-Coping model of addiction proposes that itary-adrenocortical axis, and endogenous opioid- use of addictive substances serve to both reduce peptide release to alert the body to the stressed state negative affect and increase positive affect, thereby and to support adaptation to the situation. Re- reinforcing drug taking as an effective, albeit mal- searchers have found two aspects of stressful events adaptive, coping strategy (Wills & Shiffman, that appear to mediate cognitive appraisal and the 1985). Marlatt’s Relapse Prevention model biological stress response. These are the controlla- (Marlatt & Gordon, 1985) has proposed that in VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Stress 1331 addition to other bio-psychosocial risk factors such drinking and drug use in the post-stress period as parental substance use, peer pressure, and posi- (Nash & Maickel, 1988; Piazza & LeMoal, 1996; tive expectancies regarding the potential benefits of Shaham & Stewart, 1994; Goeders & Guerin, using substances, individuals who have poor ways 1994; Miczek & Mutschler, 1996). Human labora- of coping with stressful events are at increased risk tory studies demonstrated increased use of addic- for problematic use of addictive substances. Fi- tive substances after stress as opposed to non-stress nally, the Tension Reduction Hypothesis (Conger, situations (see Marlatt & Gordon, 1985 for review). 1956; Sher & Levenson 1982) and the Self-Medi- Laboratory induction of stress has also been shown cation Hypothesis (Khantzian, 1985) have been to increase craving for addictive substances in ad- proposed stating that people use drugs to enhance dicts (Sinha et al., 1999a; 1999b). In support of the mood and alleviate emotional distress. The latter tension reduction hypothesis, some evidence has hypotheses propose that the motivation to enhance accumulated to suggest that alcohol dampens the mood may be high in the face of both acute and biological stress response in social drinkers (Sher & chronic distress states. A drug may be used initially Levenson, 1982; Finn & Pihl, 1991; Levenson et to modulate tension or distress; then with repeated al., 1987; Sinha et al., 1998), but this effect ap- success in doing so, it may become a more ubiqui- pears mediated by a family history of alcoholism tous response to stress or because of the positive and other individual difference variables. expectancies from drug effects, people may come to Converging lines of evidence cited above support use drugs in anticipation of both the relief and the key role of stress in mediating problem use of mood enhancement. addictive substances. Findings suggest that stres- Prospective studies, which measure stressful sful experiences significantly impact the vulnera- events and subjective perception of stress as they bility to increase substance use. In addition, in occur and use them to predict future drug use, have individuals using substances regularly, stressful ex- been conducted to examine whether stress increases periences may lead to an escalation of drug use to the vulnerability to drug use. Higher levels of stress the point that such use can lead to drug-related and maladaptive coping along with low parental problems for the individual. Despite the above evi- support predict escalation of drug use in adoles- dence, the specific ways in which stress increases cents (Wills et al., 1996). Evidence from animal drug intake are not well understood. Animal stud- studies further suggest that stressful experiences in ies suggest that stress alters brain reward pathways early childhood may increase the vulnerability to such that drugs are likely to feel more reinforcing drug use. Higley and colleagues (1991) studied than in non-stress conditions (Koob & LeMoal, rhesus monkeys who were reared by mothers (nor- 1997). Whether these alterations can be detected in mal condition) or by peers (stressed condition) for humans and modified to reduce the negative im- the first six months of their life. Peer-reared mon- pact of stress on drug use remains to be established keys consumed significantly more amounts of alco- in future research. hol than mother-reared adult monkeys. Further- more, when stress was increased in the adult CHRONIC DRUG USE AND monkeys via social separation, mother-reared VULNERABILITY TO STRESS monkeys increased their levels of alcohol consumption to that of peer reared monkeys. Others have The question of whether addicts are more sensi- found that rats who show greater reactivity to stress tive to the effects of stress on drug intake has and novelty show an increased vulnerability to self- received recent attention. It is now well known that administration of psycho-stimulants such as am- the most commonly used addictive substances such phetamines (Piazza et al., 1989; Piazza & LeMoal, as alcohol, nicotine, psychostimulants such as am- 1996). These findings suggest that individual re- phetamines and cocaine, opiates and marijuana sponses to stressful events and previous experience which stimulate the brain reward pathways, also of stressful events may increase the vulnerability to activate brain stress systems by stimulating release use addictive substances. of corticotrophin-releasing factor (CRF) which in Several studies have shown that acute stress in- turn activates the hypothalamic pituitary adrenal creases self-administration of drugs. Acute behav- (HPA) axis and release of catecholamines (Robin- ioral stress in laboratory animals leads to increased son & Berridge, 1993). With the chronic use of 1332 VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Stress addictive substances, hallmark symptoms of de- ways in which stress has been associated with ad- pendence emerge, namely, tolerance and with- dictive behavior. The first aspect targets vulnera- drawal, that are associated with changes in the bility to stress and use of addictive substances as a CRF-HPA, dopaminergic and catecholaminergic way of coping with stress. The second aspect of the systems (Robinson & Berridge, 1993; Koob & association has only recently received attention, LeMoal, 1997). Whether this excessive substance namely, the effect of chronic drug use on stress and use leads to significant ‘wear’ and ‘tear’ on the coping. Although the above outline presents key brain systems that it activates, such that these sys- evidence to support the important association be- tems may be unable to function normally in addicts tween stress and addictive processes, the field con- is being examined. Stewart and colleagues have tinues to develop in order to further our under- shown that in laboratory animals with a history of standing on the psychobiological mechanisms that drug taking, stress results in reinstatement of drug link stress and coping to addictive behaviors. use when the animals are drug free. However, animals experienced in self-administering food, su- (SEE ALSO: Addiction: Concepts and Definitions; crose pellets or sucrose solution, do not show a Co-morbidity and Vulnerability; Complications; stress-related increase in these behaviors. Such Endorphins; Epidemiology of Drug Abuse; Families data has led to the suggestion that it is a history of and Drug Use; Family Violence and Substance drug taking that appears to increase vulnerability Abuse; Poverty and Drug Use) to stressful events (Stewart, 2000). Finally, some human studies support the hypothesis that chronic drug use may alter stress and BIBLIOGRAPHY coping. Evidence suggests that baseline responsiv- COHEN, S. (1986). Behavior, health, and environmental ity of the CRF-HPA system is altered during acute stress. New York: Plenum. and protracted withdrawal in alcoholics and co- COHEN, S., & LICHTENSTEIN, E. (1990). Perceived stress, caine and opiate addicts (Kreek & Koob, 1998). quitting smoking, and smoking relapse. Health Psy- This co-occurs with behavioral symptoms such as chology, 9, 466-478. increases in irritability, anxiety, emotional distress, CONGER, J. J. (1956). Reinforcement theory and the dy- sleep problems, dysphoria and restlessness that are namics of alcoholism. Quarterly Journal of Studies in common during acute and protracted phases of Alcohol, 17, 296-305. withdrawal from alcohol, cocaine, opiates, nicotine TASK FORCE ON THE DSM-IV (1994). Diagnostic and and marijuana (Diagnostic and Statistical Manual- Statistical Manual-IV, American Psychiatric Associa- IV, 1994; Hughes, 1992). Furthermore, high levels tion, Washington, DC. of stress are reported in smokers who are unable to FINN, P. R., & PIHL, R. O. (1988). Risk for alcoholism: a quit, while those who abstain show lower levels of comparison between two different groups of sons of stress (Cohen & Lichtenstein, 1990). However, alcoholics on cardiovascular reactivity and sensitivity there is also evidence that stressful life events are to alcohol. Alcohol Clin Exp Res, 12, 742-747. not associated with subsequent drug use and re- FRANKENHAUSER, M. (1980). Psychobiological aspects of lapse in addicts after treatment (Hall et al., 1990; life stress. Coping and health, 203-223. New York: 1991). Future research on the psychobiological ef- Plenum Press. fects of chronic drug use as they pertain to the GOEDERS, N. E., & GUERIN, G. F. (1994). Non-contin- addicts’ ability to respond to stress and cope with gent electric shock facilitates the acquisition of intra- abstaining from drug use, would be relevant in venous cocaine self-administration in rats. Psycho- understanding the nature of this association. pharmacology, 114, 63-70. HALL, S. M., HAVASSY, B. E., & WASSERMAN,D.A. SUMMARY (1991). Effects of commitment to abstinence, positive This section outlines the key aspects of stress moods, stress, and coping on relapse to cocaine use. and coping and how they relate to addictive behav- Journal of Consulting and Clinical Psychology, 59, ior. Facing stress is basic to all organisms, but how 526-532. we cope with stress can differ significantly across HALL S. M., HAVASSY, B. E., & WASSERMAN,D.A. individuals. The above section outlines two possible (1990). Commitment to abstinence and acute stress in VULNERABILITY AS CAUSE OF SUBSTANCE ABUSE: Stress 1333

relapse to alcohol, opiates, and nicotine. Journal of interaction between stress, glucocorticoids, and dopa- Consulting and Clinical Psychology, 58(2), 175-181. minergic neurons. Annuals of Pharmacology and HENNESSEY, J. W., & LEVINE S. (1979). Stress, arousal Toxicology, 36, 359-378. and the pituitary-adrenal system: A psychoendocrine PIAZZA, P. V., DEMINIERE, J., LE MOAL, M., & SIMON,H. hypothesis. Progress in Psychobiology and Physiolog- (1989). Factors that predict individual vulnerability ical Psychology, 8, 133-178. to amphetamine self-administration. Science, 245, HIGLEY, J. D., HASERT, M. F., SUOMI, S. J., & LINNOILA M. 1511-1513. (1991). Nonhuman primate model of alcohol abuse: ROBINSON, T. E., & BERRIDGE, K. C. (1993). The neural effects of early experience, personality, and stress on basis of drug craving: an incentive-sensitization the- alcohol consumption. Proceedings of the National ory of addiction. Brain Research Reviews, 18, 247- Academy Sciences, 88, 7261-7265. 291. HUGHES, J. R. (1992). Tobacco withdrawal in self-quitt- SELYE, H. (1976). The stress of life. New York: McGraw- ers. Journal of Consulting and Clinical Psychology, Hill. 60, 689-697. SHAHAM, Y., & STEWART J. (1994). Exposure to mild KHANTZIAN, E. J. (1985). The self-medication hypothesis stress enhances the reinforcing efficacy of intravenous of addictive disorders: Focus on heroin and cocaine heroine self-administration in rats. Psychopharmaco- dependence. American Journal of Psychiatry, logy, 523-527. 142(11), 1259-1264. SHER, K. J., & LEVENSON, R. W. (1982). Risk for alcohol- KOOB, G. F., & LE MOAL M. (1997). Drug abuse: hedonic ism and individual differences in the stress-response- homestatic dysregulation. Science, 278, 52. dampening effect of alcohol. Journal of Abnormal KREEK, M. J., & KOOB G. F. (1998). Drug dependence: Psychology, 91, 350-368. Stress and dysregulation of brain reward pathways. SINHA, R., CATAPANO, D., & O’MALLEY, S. (1999a). Drug and Alcohol Dependence, 51, 23-47. Stress-induced craving and stress response in cocaine LAZARUS, R. S., & FOLKMAN, S. (1984). Stress, ap- dependent individuals. Psychopharmacology, 142, praisal, and coping. New York: Springer. 343-351. LAZARUS, R. S. (1966). Psychological stress and the SINHA, R., & O’MALLEY, S. (1999b). Craving for alcohol: coping process. New York: McGraw-Hill. findings from the clinic and the laboratory. Alcohol LEVENSON R. W., OYAMA O. N., & MEEK, P. S. (1987). and Alcoholism, 34(2), 223-230. Greater reinforcement from alcohol for those at risk: SINHA, R., ROBINSON, J., & O’MALLEY, S. (1998). Stress Parental risk, personality risk, and sex. Journal of response dampening: Effects of gender and family Abnormal Psychology, 96, 242-253. history of alcoholism and anxiety. Psychopharmaco- MARLATT, G. A., & GORDON, J. R. (1985). Relapse pre- logy, 137, 311-320. vention: Maintenance strategies in the treatment of STEWART, J. (2000). Pathways to relapse: the neurobiol- addictive behaviors. New York: Guilford Press. ogy of drug- and stress-induced relapse to drug-tak- MASON, J. W. (1975). A historical view of the stress field. ing. Journal of Psychiatry and Neuroscience, 25 (2), Journal of Human Stress, 1, 22-36. 125-136. MICZEK K. A., & MUSTSCHLER, N. H. (1996). Activation WILLS, T. A., MCNAMARA, G., VACCARO, D., & HIRKY, effects of social stress on IV cocaine self-administra- A. E. (1996). Escalated substance use: A longitudinal tion in rats. Psychopharmacology, 128, 256-264. grouping analysis from early to middle adolescence. NASH, J. F., & MAICKEL, R. P. (1988). The role of the Journal of Abnormal Psychology, 105(2), 166-180. Hypothalamic-Pituitary-Adrenocortical in post-stress WILLS, T. A., & SHIFFMAN, S. (1985). Coping and sub- induced ethanol consumption by rats. Progress in stance abuse: A conceptual framework. Coping and Neuro-Psychopharmacological and Biological Psy- substance use, 3-24. Orlando, FL: Academic Press. chiatry, 12, 653-671. LORENZO COHEN PIAZZA,P.V.,&LE MOAL, M. (1996). Pathophysiologi- ANDREW BAUN cal basis of vulnerability to drug abuse: Role of an REVISED BY RAJITA SINHA W-X

WALDEN HOUSE See Treatment Pro- current earnings and accumulated wealth. Welfare grams/Centers/Organizations: An Historical Per- programs are for very poor people and their bene- spective fits are substantially inferior to those paid by the insurance-like programs. As well,the American income maintenance sys- WAR ON DRUGS See Epidemics of Drug tem is ‘‘categorical.’’ For the most part,eligibility is Abuse; Treatment,History of; U.S. Government; based on membership in a particular category de- Zero Tolerance fined by administrative rules: Old age benefits are for those who meet the administrative definition of aged status; disability benefits are for those who meet the medical and vocational standards defining WASHINGTONIAN TEMPERANCE that category,and so forth. Except as discussed SOCIETY/WASHINGTONIANS See below in connection with General Assistance,there Temperance Movement; Treatment,History of; are no welfare programs for hale,nonelderly adults Women’s Christian Temperance Movement without children. Finally,the income maintenance system in the United States is funded and administered by fed- WELFARE POLICY AND SUBSTANCE eral,state,and local (primarily county) govern- ABUSE IN THE UNITED STATES ments. Insurance-like programs are usually funded Generally speaking,the American income mainte- and administered by the federal government,thus nance system is divided into two ‘‘tracks’’ based on creating a significant degree of uniformity in bene- the relationship of beneficiaries to the labor force. fits and eligibility rules. Welfare programs,how- For the so-called ‘‘insurance-like’’ programs,nota- ever,usually are funded and administered by two bly Old Age and Survivors Insurance (what Ameri- or more levels of government,and benefit levels cans refer to colloquially as ‘‘Social Security’’), and eligibility rules vary considerably among polit- Social Security Disability Insurance,and Unem- ical jurisdictions. ployment Compensation,eligibility is linked to an This article concerns the intersection of sub- applicant’s history of payroll deductions— stance abuse and initial and continuing eligibility contributions from wages to the public fund that for welfare programs in the context of policy supports the program. The so-called ‘‘welfare’’ changes made during the 1990s. It focuses mainly programs,on the other hand,are ‘‘means-tested.’’ on Temporary Assistance for Needy Families That is,eligibility hinges on meeting strict limits on (TANF) and,to a lesser extent,General Assistance

1335 1336 WELFARE POLICY AND SUBSTANCE ABUSE IN THE UNITED STATES

(GA). Supplemental Security Income (SSI),a fed- The PRWORA’s countermeasures are a compli- erally funded and administered welfare program cated combination of incentives and punishments for the elderly,blind,and disabled,is the subject of directed at both welfare recipients and the states. a serparate entry concerned with addiction as a The act creates a lifetime limit of 5 years’s welfare disabling impairment in the disability programs receipt for TANF families. Further,its funding administered by the Social Security Administration mechanism requires that each year the states move (see ELIMINATION OF DRUG ADDICTION AND progressively greater numbers of TANF parents ALCOHOLISM AS QUALIFYING IMPAIRMENTS IN SO- into jobs or face cuts in the overall federal grant to CIAL SECURITY DISABILITY PROGRAMS). the state (known as a ‘‘block grant’’). Each state Temporary Assistance for Needy Families. may exempt 20 percent of its caseload from job For 60 years after the enactment of the Social placement,but in the long run the states are faced Security Act of 1935,America’s cash assistance with the formidable task of making work-ready program for impoverished families was Aid to and placing in employment thousands of mothers Families with Dependent Children (AFDC; Aid to with little work experience and few marketable Dependent Children until 1961,when a parental or skills. At the same time,the PRWORA permits the caretaker grant was added). As the result of liberal states a great deal of flexibility in using various court rulings in the 1960s and the separation of funds to create training programs,support casework from the financial administration of re- childcare,and even fund alcohol and drug treat- cipients’ grants in 1972,AFDC became substan- ment. tially free of the punishing moralism that charac- The PRWORA also requires or permits the states terized an earlier era when social workers raided to enforce a variety of ‘‘behavioral requirements’’ the houses of welfare mothers to search closets for for continuing eligibility for full TANF benefits. evidence of a ‘‘man in the house’’ who might be Among these is the PRWORA’s permitting states to made to support the women and their children. mandate treatment for alcohol and drug abusers as Although various work incentives were tried over well as to require random drug testing under the the years,particularly during the 1980s,they had threat of forfeited benefits. (A failed provision of indifferent results and affected relatively few recip- the original legislation would have forced the states ients. Even so,only a small percentage of AFDC to implement these provisions.) However,recent families remained on the rolls for years at a time, research on TANF parents in some states has pro- and most AFDC heads of household,the great ma- duced the startling (to some) finding that the prev- jority of them women between 18 and 35 years old, alence of substance-abuse disorders in the adult worked part-time or intermittently while raising TANF population, as measured by a rigorous stan- their children. dard,is very similar to that in the population at However,the ascendancy of the Republican large: about 8 to 10 percent. To date,only Louisi- Party following the November 1994 elections ana,Michigan,Nevada,and New York have ex- yielded the Personal Responsibility and Work Op- pressed serious interest in drug testing and any portunity Reconciliation Act (PRWORA) of 1996 implementation plan will face a court test. How- (P.L. 104–193). The PRWORA was based on ever,a number of states,including California,are premises laid out succinctly in Contract with Amer- exploring mechanisms for mandatory treatment ica,the 1994 campaign manifesto drafted by Re- and the use of ‘‘representative payees,’’ a third publican leaders in the House of Representatives. party who receives and manages a recipient’s bene- Contract opined that the liberal welfare regime fits. dating from the 1960s ‘‘had the unintended conse- A further drug-related provision of the quence of making welfare more attractive than PRWORA is both more stringent and more com- work’’ (p. 67). Moreover: ‘‘Government programs mon. The act provides that unless a state passes designed to give a helping hand to the neediest of contrary legislation,any person with a felony drug Americans have instead bred illegitimacy,crime, conviction for conduct after August 22,1996 (the illiteracy,and more poverty.’’ Welfare reform date PRWORA was signed into law),will be ban- should thus ‘‘change this destructive social behav- ned for life from TANF benefits. This provision,it ior by requiring welfare recipients to take personal should be noted,reflects a negotiated compromise responsibility for decisions they make’’ (p. 65). on the House of Representatives version of the act WELFARE POLICY AND SUBSTANCE ABUSE IN THE UNITED STATES 1337 that would have extended the ban to those con- waiting for TANF benefits or temporarily sus- victed of misdemeanors. At this writing,nine states pended from that program; to those with an SSI (Connecticut,Kentucky,Michigan,New Hamp- application pending; or to those who are realisti- shire,New York,Ohio,Oklahoma,Oregon,and cally unemployable by some criteria of age and in- Vermont) have passed the legislation required to firmity but who do not meet the stringent disability opt out of the ban. Eighteen other states have criteria of SSI. GA programs also vary in the way passed legislation to soften it. that benefits are paid: by cash,by rent and food In 1996,about sixty-one thousand women were vouchers,or some combination. Some GA pro- convicted of drug felonies in the United States. A grams are time-limited (in Pennsylvania,e.g.). All 1997 Legal Action Center survey of seventeen drug GA programs have extremely low benefits,how- and alcohol treatment programs for women with ever. In California,the most generous GA allow- children located in different parts of the country ance is in the City and County of San Francisco, found that 21 percent of the welfare mothers in where it is about $330 per month—this in a city those programs had felony drug convictions. In the where the monthly fair market rent for a studio only study to date relevant to the TANF ban’s likely apartment now exceeds $800. effect on single mothers,attorney Amy E. Hirsch Probably because of the over representation of interviewed twenty-six affected women in Pennsyl- single men among GA beneficiaries,many jurisdic- vania,a state that has not modified the ban. Most tions estimate that the prevalence rate of alcohol were convicted of possessing small amounts of and drug problems among GA recipients is several drugs valued from four to one hundred dollars. times that of the general population. Historically, Before entering treatment (where Hirsch found GA has been the welfare program most accessible them),all had been heavy users,typically of crack to people with alcohol and drug problems. During cocaine,and most had been charged with posses- the heyday of the post-war skid row (see HOME- sion with intent to deliver. In fact,they were for the LESSNESS,ALCOHOL, AND OTHER DRUGS),many most part intermediaries and small-time corner large cities used some combination of cash,hotel girls bagging and transporting crack and engaging vouchers,and restaurant chits to keep single ad- in sex work to subsidized their habits. Often,they dicted men (mainly) roughly housed and fed with- were allowed (if not encouraged) to plead guilty to out giving them much money to handle. This sys- a felony because only by court stipulation could tem was largely abandoned as the cost of its they receive a residential treatment bed. administration rose. However,with the elimination Two-parent families may also qualify for TANF of addiction as a qualifying impairment in the SSI and the drug-felony ban may have an important program,some cities and counties are considering and negative cumulative impact on them,perhaps the revival of such arrangements,perhaps to be by discouraging drug-felon fathers from living with administered by community-based nonprofits and their families so as not to jeopardize the TANF combined with mandatory treatment and represen- benefits of the mother and children,At this writing, tative payee provisions. Other may adopt Pennsyl- there are no data on this subject. vania’s approach. There,since 1981,diagnosed General Assistance. General Assistance abusers of alcohol and/or other drugs may receive (known in some places as General Relief) is a form GA for 9 continuous months on this basis once in a of welfare financed and operated entirely by state, lifetime so long as they are in treatment. county,or municipal governments. Many states do not have GA programs,or GA exists only in some CONCLUSION local jurisdictions. GA benefit levels and eligibility rules also vary from state to state,and in some The thrust of recent federal welfare reform has states,notably California and Wisconsin,from been to rely on fiscal incentives and penalties to county to county. Some states (or smaller jurisdic- encourage welfare recipients to work and state gov- tions) provide GA benefits merely on the basis of ernments to see that they do. As a corollary,welfare need,but most GA programs are categorical (e.g., eligibility is once again being used as leverage on Oregon and Washington),restricting eligibility to the behavior of poor people and drinking and drug older people not yet eligible for Social Security or use have been salient targets of this effort—whose Supplemental Security Income (SSI); to parents complete effects remain to be seen. Given the re- 1338 WERNICKE’S SYNDROME sources (no small caveat),many state and local form of withdrawal and drug craving. According to General Assistance programs seem inclined to fol- Wikler,these CRs motivate further drug use, low suit. which,by terminating negative withdrawal feelings,perpetuates the cycle of drug dependency. BIBLIOGRAPHY At the heart of Wikler’s model lies the notion that classical conditioning mechanisms are acti- DANZIGER,S., ET AL.(1999). Barriers to the employment vated when events surrounding drug use reliably of welfare recipients. Ann Arbor,MI: Poverty Re- begin to signal upcoming drug administration. search and Training Center,University of Michigan. These events may be external cues (e.g.,the sight of EDIN,K.,and L EIN,L. (1997). Making ends meet: How a syringe) or internal states (e.g.,depression) that single mothers survive welfare and low-wage work. consistently precede drug use. In nondependent New York: Russell Sage. users (who take drugs infrequently),Wikler pro- GILLESPIE,E.,and S CHELLHAS,B. (Eds.). (1994). Con- posed that the unconditioned response (UR) elic- tract with America. New York: New York Times ited by the drug consists of direct effects of that Books. drug on the nervous sytem. In such individuals, HIRSCH,A. E. (1999). ‘‘Some days are harder than stimuli that signal drug use would then come to hard’’: Welfare reform and women with drug convic- evoke druglike responses; however,a different set tions in Pennsylvania. Washington,DC: Center for of CRs are thought to occur in long-term drug users Law and Social Policy. who have become physically dependent on the VARTANIAN,T., ET AL. (1999). Already hit bottom: Gen- drug. These individuals experience withdrawal eral Assistance,welfare retrenchment,and single symptoms as the drug effect wanes and conse- male migration. In S. F. Schram & S. H. Beer (Eds.), quently,stimuli associated with drug withdrawal in Welfare reform: A race to the bottom? (pp. 111–127). these individuals evoke withdrawal reactions. Washington,DC: Woodrow Wilson Center Press. The aversive symptoms produced by withdrawal JIM BAUMOHL in dependent users provide motivation to self- administer the drug. Through a process of operant conditioning,drug taking is rewarded by the termination of the negative withdrawal symptoms. These WERNICKE’S SYNDROME See reward experiences further strengthen the tendency Alcoholism; Complications: Neurological of the drug user to turn to drug use when experiencing withdrawal symptoms. Likewise,stimuli paired temporally with withdrawal may also acquire the WIKLER’S PHARMACOLOGIC THE- ability to elicit drug taking. Because Wikler ORY OF DRUG ADDICTION Abraham invoked both classical and operant conditioning Wikler (died 1981) was one of the first researchers mechanisms as contributors to drug use,his model who,in the late 1940s,strongly advocated the idea has often been characterized as a two-process that drug abuse and relapse following treatment model of drug use. are influenced by basic learning processes. Early in Wikler’s model also provides for a powerful ac- his career,Wikler became interested in reports count of relapse following treatment for drug use. from relapsed heroin addicts that despite being free Because some treatment programs separate the of withdrawal symptoms during treatment and abuser from the drug-use environment,the patient upon discharge,they experienced withdrawal never learns to deal with drug-related events. Upon symptoms and craving when they returned to their returning home following treatment,even though drug-use environments—and that these feelings no longer physically dependent,the patient en- were responsible for their return to drug use. counters drug signals,experiences conditioned Based on these and other anecdotes,Wikler— withdrawal reactions,and eventually turns to drug who was familiar with the recent work of Russian use to reduce the negative feelings. Since condi- physiologist Ivan Petrovich Parlor (1849–1936) on tioned responses show little spontaneous decay over conditioning—proposed that events which reliably time,the drug-use patient is at risk even following signal drug self-administration or drug withdrawal an extended treatment program. According to elicit conditioned responses (CRs) that take the Wikler,treatment programs need to address condi- WITHDRAWAL: Alcohol 1339 tioned responses directly. One suggested approach Alcohol The nervous system undergoes adap- involves having subjects go through their usual tation in response to the chronic consumption of drug-preparation ritual in a protected setting, alcohol (ethanol). If consumption is heavy enough where drugs are not available. Such exposures (adequate dose) and occurs for a long enough time should serve to extinguish drug-use responses by period (duration),a withdrawal syndrome will failing to reinforce them with relief from with- ensue following a rapid decrease or sudden cessa- drawal. Extinction training as well as other tech- tion of drinking. This occurs in association with niques for reducing the role of conditioned re- readaptation of the nervous system to a drug-free sponses in relapse are currently being explored. state. The dose and duration of alcohol consumption required to produce a withdrawal syndrome in a given population or even a given individual are (SEE ALSO: Behavioral Tolerance; Causes of Sub- difficult to predict,since no well-controlled studies stance Absue: Learning; Naltrexone; Research, An- have been conducted (or are likely to be,for ethical imal Model: Learning, Conditioning and Drug Ef- reasons). Such studies have been done in animals. fects) The goals of treatment are to relieve discomfort and to prevent complications. BIBLIOGRAPHY In the nondrinker or social drinker who consumes alcohol to the point of legal intoxication,an WIKLER,A. (1977). The search for the psyche in drug acute withdrawal syndrome may ensue (‘‘hang- dependence. Journal of Nervous and Mental Disease, over’’). Symptoms occur in inverse relation to the 165,29–40. fall in BLOOD ALCOHOL CONCENTRATION (BAC). WIKLER,A. (1973). Dynamics of drug dependence: Im- These consist of insomnia,headache,and nausea. plications of a conditioning theory for research and Usually no treatment is required and there are no treatment. Archives of General Psychiatry, 28,611– serious consequences of this acute withdrawal. The 616. withdrawal syndrome following chronic long-term WIKLER,A. (1965). Conditioning factors in opiate addic- alcohol consumption (usually months to years), tion and relapse. In D. I. Wilner & G. G. Kassenbaum however,is a more serious disorder. (Eds). Narcotics. New York: McGraw-Hill. The natural history of alcohol dependence to the WIKLER,A. (1948). Recent progress in research on the point of requesting or clearly requiring detoxifica- neurophysiologic basis of morphine addiction. Ameri- tion services is usually fifteen to twenty years. The can Journal of Psychiatry, 105,329–338. average age of persons admitted to detoxification units is around 42 years. (That is not to say that STEVEN J. ROBBINS persons as young as 20 or as old as 80 do not require detoxification services.) The withdrawal syndrome seen in persons requiring detoxification WINE See Alcohol; Fermentation ranges from a mild degree of discomfort to a potentially life-threatening disorder. The severity of the withdrawal syndrome is de- WITHDRAWAL This section contains the pendent on both the dose and duration of alcohol articles on withdrawal syndromes,each of which exposure. This is clearly demonstrated in animal describes and discusses withdrawal signs,symp- studies (rats) where a severe withdrawal syndrome toms,and treatment. The following substances are can be demonstrated following high-level exposure covered: Alcohol; Benzodiazepines; Cocaine; Nic- to alcohol in a vapor chamber in as short a time otine (Tobacco); and Nonabused Drugs. For de- period as a week. Administration of alcohol into the scriptions and discussions of withdrawal from Am- stomach is associated with a longer time period for phetamines,see Amphetamine; Anabolic Steroids, acquisition of physical dependence. In humans see Anabolic Steroids; Barbiturates,see Barbitu- also,the severity of withdrawal depends on the rates; Caffeine,see Caffeine; Cannabis,see Canna- amount of alcohol consumed and the time period bis,see also Marijuana; for Heroin,Opiates/Opi- during which it has been consumed. For practical oids,see Opioid Complications and Withdrawal. purposes this means the amount taken on a daily For additional information,see also Treatment. basis for the weeks and months preceding detoxifi- 1340 WITHDRAWAL: Alcohol

cation. One study of inpatients (who were federal drawal syndrome (Shaw et al.,1981). This in part prisoners and narcotic users) demonstrated that the relates to the lack of accurate recall of exact quan- consumption of 442 grams of alcohol or 32 stan- tities consumed within a given time period. Fur- dard drinks (a standard drink being 13.6 gm of thermore,in the real world there are different pat- alcohol—12 oz. of beer,5 oz. of wine,or 1.5 oz. of terns of consumption (e.g.,some drinkers consume liquor) per day for about two months results in a alcohol in a binge pattern,whereas others drink in major withdrawal syndrome in all subjects, a more regular pattern),and different drinkers whereas the consumption of 280 to 377 grams (21 have varying durations of lifetime exposure to alco- to 28 standard drinks) per day results in a mild hol. One drinker may take two or three years to syndrome of anxiety and tremor (Isbell et al., become dependent,another ﬁfteen years,and yet 1955). Other studies that involve patients (as op- another forty years. In addition,a person who has posed to research subjects) have not been able to previously experienced signiﬁcant alcohol with- demonstrate a consistent relationship between re- drawal may be at higher risk for developing repeat cent alcohol consumption and severity of the with- withdrawal,both in terms of the severity of the WITHDRAWAL: Alcohol 1341

syndrome and the rate of reacquisition of physical in the morning to ‘‘steady the nerves,’’ to suppress dependence (since it takes a shorter time to become tremor and anxiety. The following are some of the re-addicted). This more rapid reacquisition has more common symptoms of alcohol withdrawal: been attributed to sensitization (or ‘‘kindling’’) of anxiety,agitation,restlessness,insomnia,feeling the central nervous system (Linnoila et al.,1987). shaky inside,anorexia (loss of appetite),nausea, Other factors that may be implicated in the severity changes in sensory perception (tactile: skin itchy; of the withdrawal syndrome include age,nutri- auditory: sounds louder; visual: light brighter), tional status,and presence of concurrent physical headache,and palpitations. Common signs include disorders or illness (e.g.,pancreatitis or pneumo- vomiting,sweating,increase in heart rate,increase nia) (Sullivan & Sellers,1986). Alcoholics are at in blood pressure,tremor (shakiness of hands and increased risk for these and other medical disor- sometimes face,eyelids,and tongue),and seizures. ders. More severe withdrawal is associated with intensiﬁ- The symptoms and signs of alcohol withdrawal cation of the above symptoms and signs together appear in inverse relation to the elimination of with progression to hallucinations (tactile: feeling alcohol from the body. Many alcoholics note this things that are not there; auditory: hearing things phenomenon on a daily basis—they require a drink that are not there; visual: seeing things that are not 1342 WITHDRAWAL: Alcohol

there),disorientation,and confusion (D ELIRIUM withdrawal,very few adequate scientific studies TREMENS,DTs). After stopping alcohol,the more have been conducted—the main reasons being that common and milder symptoms usually peak at 12 appropriate studies are difficult to conduct and that to 24 hours and have mostly subsided by 48 hours many patients do very well with placebo and/or (Sellers & Kalant,1976). More severe or late with- supportive care alone. Nevertheless,appropriate drawal usually peaks later,72 to 96 hours,and is and effective specific treatments are available and potentially life threatening. Less than 5 percent of consist of drugs belonging to the same general class persons withdrawing from alcohol (depending on as alcohol (central nervous system depressants). how they are selected) are estimated to develop a The drugs of choice are the longer-acting benzodi- severe reaction. With appropriate drug treatment, azepines (usually diazepam [Valium],but others an even lower percentage are estimated to develop a include chlordiazepoxide [Librium],lorazepam major withdrawal reaction. Under ideal circum- [Ativan],and oxazepam [Serax]),or occasionally a stances there should be almost no mortality from long-acting barbiturate like phenobarbital. The this disorder on its own,so overall mortality ought specific drug treatment is usually given either be- to be similar to that of any concurrent medical fore most withdrawal has occurred (substitution or disorder. prophylactic treatment) or after significant symp- Assessment of the severity of withdrawal can be toms and signs manifest themselves (suppressive accomplished on the basis of clinical experience or treatment). The advantages of substitution treat- with the assistance of various rating instruments. ment include the prevention of potential discomfort One of the simplest and easiest to administer is the and the possible prevention of more severe with- Clinical Institute Withdrawal Assessment for Alco- drawal. The disadvantages include an unnecessary hol-revised (CIWA-Ar). This consists of ten items treatment for some patients. The advantages of that can be scored at frequent intervals (Sullivan et suppression treatment include more appropriate tial.,1989). The health-care provider can administer tration of dose of medication,according to a given this instrument in less than a minute (see Figure 1). patient’s needs. The disadvantages include unnecessary patient discomfort,at least initially,possibly TREATMENT the development of more severe withdrawal,and sometimes drug-seeking behavior from patients Treatment for the alcohol withdrawal syndrome and unnecessary drug withholding from staff. consists of supportive care,general drug treatment, BENZODIAZEPINES have been well demonstrated and specific drug treatments. Supportive care con- to prevent complications (Sellers et al.,1983) of sists of reassurance,reality orientation,reduced serious withdrawal,such as seizures,H ALLUCINA- sensory stimuli (dark,quiet room),attention to TIONS,and cardiac arrhythmias. In general,high fluids,nutrition,physical comforts,body tempera- doses of these benzodiazepines (with medium to ture,sleep,rest and positive encouragement toward long half-lives) are provided early in treatment,to long-term rehabilitation. The majority of patients cover the patient for the time period of acute with- can be treated with supportive care alone; however, drawal (usually 24 to 48 hours). Some patients it is impossible to be able to predict which patients require very large doses of drug (e.g.,several hun- will or will not require more intensive care. General dred milligrams of diazepam) to suppress symp- drug treatment includes the B vitamin thiamine, toms and signs. Patients with histories of with- which should be given to all patients. This is given drawal seizures (convulsions) or those that have to prevent the brain damage that occurs commonly epilepsy are always treated prophylactically,usu- in alcoholics who are thiamine deficient. Occasion- ally with benzodiazepines and any other anticon- ally magnesium may be given if there is a severe vulsant drug (medication) that they are prescribed deficiency and there are potential cardiac prob- on a regular basis. Patients who develop hallucina- lems. Intravenous fluids may be required in uncom- tions are given (in addition to benzodiazepines) a mon circumstances. phenothiazine (neuroleptic or antipsychotic drug). Specific drug treatments may also be given to Typical drugs from this class include haloperidol suppress the signs and symptoms of withdrawal. (Haldol),and chlorpromazine (Thorazine). These While over a hundred drug treatments have been drugs are effective in the treatment of hallucina- suggested as useful in the treatment of alcohol tions. WITHDRAWAL: Benzodiazepines 1343

SUMMARY applied to drugs of abuse,these symptoms are sometimes called abstinence syndrome or dis- In summary,alcohol withdrawal syndrome is a continuance syndrome when associated with ben- constellation of symptoms and signs that accom- zodiazepines,thereby distinguishing these sub- pany the detoxiﬁcation and readaptation of the stances from drugs such as ALCOHOL,OPIOIDS, nervous system to a drug-free state in chronic COCAINE,and B ARBITURATES. users. In most cases,these signs and symptoms are a source of mild discomfort and run a self-limited course. Occasionally,more severe withdrawal oc- ETIOLOGY curs or patients have concurrent complications Not all patients who take benzodiazepines will (e.g.,seizures). Under these circumstances appro- experience a discontinuance syndrome when the priate drug treatment is mandatory to relieve drug is stopped. Several conditions must be present symptoms and prevent complications. before the discontinuance syndrome is likely:

BIBLIOGRAPHY 1. Duration of treatment. The benzodiazepine must be taken long enough to produce altera- ISBELL,H., ET AL. (1955). An experimental study of tions in the CNS that will predispose to a dis- ‘‘rum fits’’ and delirium tremens. Quarterly Journal of continuance syndrome. When benzodiazepines Studies on Alcohol, 16,1–33. are taken at therapeutic doses,the range of time LINNOILA,M., ET AL. (1987). Alcohol withdrawal and that usually produces a discontinuance syn- noradrenergic function. Annals of Internal Medicine, drome is from several weeks to several months. 107,875–889. Taking benzodiazepines once or twice during a SELLERS,E. M.,& K ALANT,H. (1976). Alcohol intoxica- crisis,or even for several weeks during a pro- tion and withdrawal. New England Journal of Medi- longed period of stress,ordinarily does not set cine, 294,757–762. the stage for discontinuance symptoms. SELLERS,E. M., ET AL. (1983). Oral diazepam loading: 2. Dose. The amount of drug taken on a daily or Simplified treatment of alcohol withdrawal. Clinical nightly basis is also a critical factor. When Pharmacology and Therapeutics, 34,822–826. higher-than-therapeutic doses are taken—for SHAW,J. M., ET AL. (1981). Development of optimal tac- example,for treatment of panic disorder—then tics for alcohol withdrawal. 1. Assessment and effec- the period required before a discontinuance syn- tiveness of supportive care. Journal of Clinical Psy- drome may develop is shortened. chopharmacology, 1,382–389. 3. Abrupt discontinuance of the benzodiazepine. SULLIVAN,J. T.,& S ELLERS,E. M. (1986). Treating alco- Discontinuance symptoms arise because the hol,barbiturate,and benzodiazepine withdrawal. Ra- level of drug at the CNS receptor sites is sud- tional Drug Therapy, 20,1–8. denly diminished. Since drug level in the CNS is SULLIVAN,J. T., ET AL. (1989). Assessment of alcohol proportional to the amount circulating through- withdrawal: The revised Clinical Institute Withdrawal out the body,an abrupt decline in CNS drug Assessment Scale for Alcohol (CIWA-Ar). British levels occurs when the blood level abruptly Journal of Addiction, 84,1353–1357. drops. Gradual tapering of benzodiazepines JOHN T. SULLIVAN usually prevents the appearance or reduces the REVISED BY JAMES T. MCDONOUGH,JR. intensity of discontinuance symptoms. 4. Type of benzodiazepine. Benzodiazepines are classified into short and long half-life com- Benzodiazepines Like many other drugs pounds. These terms refer to the time it takes for that alter central nervous system (CNS) liver metabolism to remove (clear) benzodiaze- NEUROTRANSMISSION,benzodiazepines may pro- pines from the body. Short half-life benzodiaze- duce a withdrawal syndrome when the drugs are pines are cleared very rapidly,usually from 4 to abruptly discontinued. These withdrawal symp- about 16 hours,depending on the drug. In con- toms,including increased A NXIETY and insomnia, trast,long half-life benzodiazepines may take are often the mirror image of the therapeutic effects anywhere from 24 to 100 or more hours to be of the drug. Since the term withdrawal is usually cleared. Since the appearance of discontinuance 1344 WITHDRAWAL: Benzodiazepines

symptoms depends,in part,on the rapidly di- exist before the patient took benzodiazepine appear minishing blood level of the drug,abrupt cessa- after discontinuance; these are termed true with- tion of the short half-life benzodiazepines is drawal symptoms,indicating a change in CNS more likely to produce discontinuance symp- functioning. Usual withdrawal symptoms include toms. Controversy exists about whether other headache,anxiety,insomnia,restlessness,depres- factors that distinguish one benzodiazepine sion,irritability,nausea,loss of appetite,gastroin- from another are associated with the appear- testinal upset,and unsteadiness. Patients may also ance of a discontinuance syndrome. experience increased sensitivity for sound and smell,difficulty concentrating,and a sense that MANIFESTATIONS events are unreal (depersonalization). Unusual withdrawal symptoms include psychosis and sei- Virtually all who experience discontinuance zures. symptoms from benzodiazepines describe increased anxiety,restlessness,and difficulty falling OCCURRENCE OF SEIZURES asleep. These symptoms may be mild,little more than an annoyance for a few days,or they may be From a medical perspective,the most serious of quite severe and even more intense than the symp- all discontinuation symptoms is the development of toms of anxiety or insomnia for which the drugs withdrawal seizures. Seizures are generally grand were initially prescribed. The reappearance of the mal in type (tonic-clonic; epileptic) and may initial symptom,such as anxiety or insomnia,only threaten the life of the patient. They tend to occur in greater severity,is known as the rebound symp- only when higher-than-therapeutic doses are tom. Rebound symptoms usually occur within abruptly discontinued. hours to days of benzodiazepine discontinuance Withdrawal seizures almost always occur when and then gradually fade. In some cases,however, the patient has been taking other drugs,such as they may be so intense that the patient resumes ANTIDEPRESSANTS or ANTIPSYCHOTIC agents,to- taking the benzodiazepine to avoid the dis- gether with a benzodiazepine. continuance symptoms themselves. Thus a cycle of benzodiazepine dependence may begin—the pa- COEXISTING PSYCHOPATHOLOGY tient is taking the drug primarily to treat or prevent Apparently some people are more predisposed to rebound discontinuance symptoms from appear- develop the discontinuation syndrome than others. ing,rather than treating an underlying anxiety or Those who have been previously dependent on ben- sleep disorder. zodiazepines,alcohol,or other S EDATIVE-HYP- Benzodiazepines that are given to induce sleep NOTIC drugs,such as barbiturates,are more likely may also be associated with the development of to experience discontinuance symptoms after the discontinuance symptoms. Rebound insomnia,the termination of benzodiazepine therapy. It is espe- most common discontinuance symptom,typically cially important,therefore,that such patients never occurs on the first night and sometimes the second stop taking their benzodiazepines abruptly. night after discontinuance of short half-life benzodiazepines. Rebound insomnia may be so intense TREATMENT during these nights that the patient may be unwilling to risk another sleepless night and so returns to Although a variety of treatments have been pro- taking the benzodiazepine hypnotic. Rebound in- posed for the discontinuance syndrome,the best somnia is less common with long half-life benzodi- approach is to prevent its occurrence. Logically, azepines. prevention consists of a very gradual tapering of If untreated,rebound symptoms may sometimes the benzodiazepine dose,with a firm rule never to persist for many months. When this occurs it is discontinue these medications abruptly if they have difficult to determine whether the symptoms are been taken for more than a few weeks on a regular still manifestations of discontinuance or are the basis. result of the return of the problems (anxiety,in- Even with gradual tapering,however,some pa- somnia) for which the drug was originally pre- tients may continue to experience rebound or with- scribed. Sometimes new symptoms that did not drawal symptoms that are sufficiently disturbing to WITHDRAWAL: Cocaine 1345 require treatment. Drugs that tend to reduce CNS (rarely) seizure. Craving,or desire,for alcohol is hyperarousal states,such as anticonvulsants,have typically high during this period,since the drinker sometimes been employed to treat benzodiazepine knows it will quickly relive the withdrawal symp- discontinuance. Alternatively,benzodiazepine toms. These symptoms and signs will generally re- treatment is restarted using a long half-life com- solve within three to ten days of ceasing the intake pound that is then very gradually tapered. of alcohol. Finally,the withdrawal syndrome is reproduceable—individuals tend to experience the CONCLUSION same symptoms every time they withdraw from alcohol. Withdrawal from OPIATES such as HEROIN For the great majority of patients,benzodiaze- and MORPHINE similarly involves physiologic pine discontinuance is a relatively benign and symptoms and signs—diarrhea,gooseflesh, short-lived syndrome; many,if not most,patients changes in pulse and blood pressure,muscle have no difficulty. It is generally agreed that the cramps,stomach cramps,and anxiety. therapeutic benefits of taking benzodiazepines far In the cocaine abuser,the absence of early ap- outweigh any problems with discontinuance when parent physiologic symptoms and signs of cocaine drug treatment is no longer necessary. withdrawal led to a widely held misperception (among the public and medical professions BIBLIOGRAPHY alike)—that cocaine was not an addicting drug. This misperception was based in part on cocaine’s RICKELS,K., ET AL. (1993). Maintenance drug treatment lack of a withdrawal syndrome that was as easy to for panic disorders. Archives of General Psychiatry, characterize as those associated with alcohol or 50,61. opioids. SALZMAN,C. (1991). The APA Benzodiazepine Task If cocaine withdrawal does not evidence physio- Force Report on dependency,toxicity,and abuse. logic symptoms and signs,then how can it be recog- American Journal of Psychiatry, 148,151–152. nized? The concept has been advanced that cocaine SALZMAN,C., ET AL. (1990). American Psychiatric Asso- withdrawal is mediated through the central ner- ciation Task Force on benzodiazepine dependency, vous system,that observable symptoms are limited toxicity, and abuse. Washington,DC: American Psy- to subjective states such as depression,lack of en- chiatric Press. ergy,agitation,and craving for cocaine. Evidence CARL SALZMAN that neurophysiologic dysfunction may underlie reported symptoms consists of electroencephalogram (EEG) changes,neurohormonal dysregulation,and Cocaine Withdrawal from cocaine was men- dopamine-receptor alteration (Satel et al.,1993). tioned by H. W. Maier in his 1928 classic Der In 1986,Gawin and Kleber were among the first Kokainismus (Cocaine Addiction),but systematic to describe the clinical course of the symptoms fol- efforts to describe and understand cocaine with- lowing cocaine cessation,and they proposed a drawal did not begin until the 1980s,during the three-phase model of cocaine abstinence. Although most recent epidemic. this triphasic model has gained wide acceptance, The features of withdrawal from depressant other recent data suggest the model may not be drugs such as ALCOHOL and OPIOIDS are more ro- applicable in all clinical situations,as will be dis- bust and recognizable than from a stimulant drug cussed below. such as cocaine—since the grossly observable pat- The triphasic model postulated by F. Gawin and tern of physiologic disturbances seen in depressant H. Kleber on the basis of interviews with outpa- withdrawal syndromes are not observed when a tients comprises three phases that occur after co- person stops using cocaine. This difference high- caine cessation: (1) crash,(2) withdrawal,and lights and contrasts depressant withdrawal and (3) extinction. The crash is described as an extreme stimulant withdrawal,such as is seen with cocaine. state of exhaustion that follows a sustained period In alcohol withdrawal,for example,the drinker of cocaine use (binge); it can last between nine may manifest all or several of the following set of hours and four days. The beginning of the crash is symptoms and signs: tremulousness,elevated pulse marked by craving,irritability,dysphoria,and agi- and blood pressure,sweatiness,nervousness,and tation; the middle is characterized by yearning for 1346 WITHDRAWAL: Cocaine

sleep; and the late crash by hypersommnolence newly abstinent COCAINE-dependent males were (excessive sleep). Certain individuals may experi- observed during a 21-day hospitalization. Over the ence especially severe depressed mood in the early 21 days,both subjective and objective ratings of stages of cocaine abstinence and are at risk for mood and arousal showed gradual improvement. suicidal ideation and action at this time. This may Although all subjects had consumed cocaine within be particularly true for those who are struggling twenty-four hours of admission,some claimed that with ongoing problems with depression. When al- they had slept prior to admission and thus the crash cohol is used with cocaine,depressed mood can phase may have been missed in both studies. intensify. Also alcohol-induced reduction of im- The major differences between the triphasic pulse control,combined with cocaine crash-related model and the reports made by the two groups of despair,creates a high-risk situation for suicide. investigators who actually observed cocaine users As depression and desire for sleep increase, during withdrawal reside in the euthymic interval, craving subsides. Upon awakening from a lengthy the severity of symptoms,and the time-to-recovery sleep,the individual enters a brief euthymic (nor- of mood and craving. Nevertheless,all three studies mal) period with mild craving. This is followed by a are consistent with at least a mild postcessation protracted period of milder withdrawal,lasting 1 syndrome. It may be important that the original to 10 weeks,during which time craving reemerges conceptualization of the triphasic cocaine with- and anhedonia (loss of pleasure) prevails. This is drawal was derived from observations of outpa- succeeded by an indefinite period of extinction, tients. The subsequent studies involved inpatients, marked by euthymic mood and episodic craving. who were largely protected from environmental According to the triphasic model,protracted cues. withdrawal is represented by phase 3,thus begin- Divergent findings with respect to a delineation ning after two weeks or more. These clinical phe- between acute and protracted withdrawal is related nomena are believed to reflect disturbances in cen- to the difficulty in distinguishing acute cocaine tral catecholamine (neurotransmitter) function withdrawal symptoms from those that characterize produced by long-term cocaine use. The crash protracted withdrawal. (This distinction is less phase,however,can occur even in first-time stimu- blurred in alcohol and opiate withdrawal,where lant users—if their initial episode is of sufficient the intense physiologic symptoms take place within duration and dose. the first week of ceasing usage—and the protracted Recently,two groups of investigators have ob- syndromes,though uncomfortable,are considera- served a mild constellation of subjective features of bly milder.) Conditioned withdrawal symptoms the post-crash cocaine abstinence syndrome as de- have been documented in opiate users and in alco- scribed by Gawin and Kleber,but without the holics. These represent actual physiologic corre- phases those investigators described. Weddington lates of pharmacologic withdrawal (e.g.,changes in et al. (1990) documented the absence of cyclic or skin temperature,gooseflesh,diarrhea,and phasic changes in mood states,cocaine craving,or cramps,accompanied by intense craving for the interrupted sleep in twelve cocaine-dependent in- drug) elicited in drug-free individuals after they patients examined during a four-week period. All complete acute withdrawal and are exposed to re- had abstained from continuous cocaine use within minders of drug use (e.g.,visual or olfactory cues). the preceding forty-eight hours. No euthymic win- Conceivably,Gawin and Kleber’s subjects may dow was evident,although subjects reported signif- have experienced a delineated withdrawal,with a icantly greater depressed mood than nondrug-us- clear transition to a protracted state—because as ing controls at admission. Subjective symptoms of outpatients they were constantly exposed to envi- mood,craving,and anxiety displayed a steady and ronmental cues and reminders of drug use. In in- gradual improvement during the course of the patients,symptoms of acute cocaine withdrawal study. By the end of week 4,the cocaine users and may be less clearly delineated. Constant exposure the nondrug-using controls had comparable scores. to cues may intensify a clinically observable acute Thus,withdrawal had been completed over the syndrome,making the acute-protracted distinction course of one month. easier to recognize. Environmental influences on Similar subjective findings emerged from a clinical withdrawal may determine,in part,the study by Satel and coworkers (1991),in which 22 severity of the observable manifestations of WITHDRAWAL: Cocaine 1347

changes in neuroreceptors and neurotransmitters Cocaine CRAVING is the major cause of relapse in that accompany chronic cocaine use. Clearly,the individuals trying to attain and sustain abstinence. behavioral and subjective manifestations are Such craving is typically most severe in the early variable. stages of withdrawal from cocaine,although,as In addition,it is possible that nonorganic factors Gawin and Kleber noted in their model,cocaine play a role in the prolonged psychic distress follow- addicts are extremely cue-responsive; reminders of ing termination of the chronic use of cocaine. In- drug use in the community (old copping areas, deed,the period of abstinence following heavy drug people with whom they used to get high,etc.) can use is a time when addicts must squarely face the stimulate craving at any stage of abstinence. Thus, shambles of their lives—the destruction of their people with severe addiction trying to relinquish families,loss of jobs,financial ruin,insults to cocaine must often enter a rehabilitation program health and self-esteem. Cocaine craving during this with an outpatient phase that lasts from one to two period is likely triggered by negative mood states as years,at minimum. well as a conscious desire to obliterate the psycho- Ideally,a heavy cocaine user with good social logical pain with more drug—a return to drug use. support and resources could enter an inpatient pro- Pharmacologic treatment for the crash phase of gram to undergo detoxification (when sustained withdrawal has received attention,although most craving is usually at its peak) for a minimum of one treatment centers do not use medicines to help de- week,before beginning outpatient work. Individu- toxify crashing cocaine addicts. The two major als without social support or a stable living situa- drugs that have been reported useful during the tion can often benefit from weeks to months in a crash phase are bromocriptine and AMANTADINE. residential-treatment setting. Since it appears that The action of these two drugs is to enhance trans- the immediate postcessation phase may be milder mission of the NEUROTRANSMITTER dopamine. In- for inpatients,this might be a way for addicts to deed,drugs that have this action were specifically experience less distress and to better concentrate on chosen by investigators for use in treatment trials, therapy and education. It might also be a period of because they assumed such drugs would reverse the time when they feel a somewhat greater sense of reduction in dopamine levels in the brain that nor- control over themselves—control being especially mally follows cocaine binging. This reduction is difficult to achieve when craving for cocaine is presumed to account for the depression,irritability, high. It is critical to realize,however,that many agitation,and drug craving during the crash phase. patients can develop a false sense of control over Pharmacotherapy for detoxifying cocaine ad- the addiction because as inpatients they are protec- dicts becomes especially important when a person ted from environmental cues that trigger craving. is also dependent on alcohol or opioids. Such code- Thus gradual reintroduction to the ambulatory en- pendent states are very common. The usual choice vironment,psychological preparation of the patient for alcohol detoxification is a BENZODIAZEPINE drug for the likely return of craving,and therapy using (e.g.,Librium); for opiate withdrawal,a choice relapse-prevention techniques (a form of cognitive exists for METHADONE,CLONIDINE,NALTREXONE, therapy) are all necessary. or combinations of these. Important interactions occur between cocaine and other drugs of abuse. (SEE ALSO: Amphetamine; Cocaine ) For example,cocaine plus alcohol in the body produces a compound called COCAETHYLENE. This BIBLIOGRAPHY compound produces more intense and longer euphoria—but it also heightens the risk of death,due GAWIN,F. H. (1991). Cocaine addiction: psychology and to cardiac arrythmia. Also,in methadone clinics, neuropsychology. Science (March 29),1580–1585. cocaine use has been noted to be of epidemic pro- GAWIN,F. H.,& K LEBER,H. D. (1986). Abstinence portion; the opiate methadone mediates the jit- symptomatology and psychiatric diagnosis in chronic teriness and paranoia that often accompanies co- cocaine abusers. Archives of General Psychiatry, 43, caine use. Some evidence shows that cocaine 107–113. addicts,who are also dependent on opiates,may MAIER,H. W. (1928/1987) Der kokainismus (Cocaine have less severe opiate withdrawal than those who Addiction),O. J. Kalant (Trans.). Toronto: Addiction do not use cocaine. Research Foundation. 1348 WITHDRAWAL: Nicotine (Tobacco)

SATEL,S. L., ET AL. (1993). Should protracted with- NICOTINE TOLERANCE drawal from drugs be included in DSM-IV? American AND DEPENDENCE Journal of Psychiatry, 150,695–701. Nicotine is the pharmacologic agent that acts SATEL,S. L., ET AL. (1991). Clinical phenomenology and on the central nervous system (CNS). Its actions neurobiology of cocaine abstinence: A prospective in- are seen in the brain where it operates on cholin- patient study. American Journal of Psychiatry, 148, ergic receptors. The cigarette is a very fast and 1712–1716. effective delivery system and effects occur rapidly WEDDINGTON,W. W., ET AL. (1990). Changes in mood, after a single inhalation of tobacco smoke. Nic- craving and sleep during short-term abstinence re- otine quickly crosses the blood–brain barrier and, ported by male cocaine addicts: A controlled residen- once in the brain,interacts with brain receptors. tial study. Archives of General Psychiatry, 47,861– Nicotine alters moods and acts on pleasure-seek- 868. ing receptors in the brain,including dopamine SALLY L. SATEL and serotonin. The nicotine alkaloid affects nu- THOMAS R. KOSTEN merous body systems: It raises blood pressure and the heart rate. It also affects the peripheral nervous system (PNS) and both stimulant and de- Nicotine (Tobacco) Nicotine is one of the pressive effects are observed in cardiovascular, most addicting substances known; indeed,the risk endocrine,gastrointestinal,and skeletal systems. of becoming dependent on nicotine following any Initial exposure to nicotine is not a pleasant ex- tobacco use is higher than the risk of becoming perience,often causing sickness,intoxication,and dependent on alcohol,cocaine,or marijuana fol- disruptions in physiologic functioning. After a pe- lowing any use of those substances. Among multi- riod of daily smoking (assumed to be at least a few ple drug users,quitting tobacco use is often cited as weeks),the body adapts to nicotine and the unpleasant effects are less pronounced. Tolerance de- more difficult than giving up alcohol or cocaine. velops and physical dependence occurs. Smokers Most current views of tobacco use include physio- are free to self-administer the dose of nicotine they logical addiction as a factor in the difficult course of desire,and tolerance increases so that the amount achieving smoking cessation. of nicotine used per day continues to increase. The As with other drugs that result in dependency, level of dependence is strongly related to the dose of nicotine,the active ingredient in tobacco,shares nicotine. characteristics with other drugs that result in ad- As a smoker becomes physically dependent on, diction. First,the administration of such drugs that is,addicted to,smoking,the smoker feels nor- alters central nervous system function at specific mal,comfortable,and effective when taking nic- receptors and often changes structure; in addition otine,and dysphoric,uncomfortable,and ineffec- increases (up regulation) or decreases (down regu- tive when deprived of nicotine. The process of lation) in receptor numbers occur. Second,re- dependence development weakens the ability of the peated exposure to the drug results in tolerance, person to achieve and sustain even short-term ab- and the individual must progressively self-adminis- stinence. Thus,in the nicotine-dependent person, ter higher doses of the drug to obtain the same ‘‘normal’’ function depends on nicotine,and the effects that initially occurred at lower doses. Third, removal of nicotine results in impairment. as cellular and neurological functioning adapt to the continuous presence of the drug during toler- NICOTINE WITHDRAWAL SYMPTOMS ance development,a state of physical or physiological dependence is produced so that removal of the The DSM-IV recognizes nicotine dependence as drug is accompanied by feelings of dysphoria and a substance-related disorder,with a well-defined an inability to function normally. The individual withdrawal syndrome. The potential withdrawal then needs continued drug intake to function nor- symptoms include dysphoric or depressed mood; mally. Finally,a hallmark of dependence-produc- insomnia; irritability,frustration,or anger; anxi- ing drugs is that they serve as biological reinforcers ety; difficulty concentrating; restlessness; de- for animals,including humans. creased heart rate; and increased appetite or WITHDRAWAL: Nicotine (Tobacco) 1349 weight gain. The severity of the symptoms will depend on the severity of nicotine dependence. Withdrawal symptoms are strongest in the first few days after smoking cessation,and usually diminish within a month,although some smokers may continue to have withdrawal symptoms for many months. A number of other sequelae accompany smoking cessation. There is evidence that cognitive ability is impaired when smoking cessation is attempted. The cognitive deficits are correlated with disruptions in brain electrophysiologic function. Figure 1 shows that deficits in an arithmetic task follow a similar time course as changes in the brain’s electrical activity. These effects begin a few hours after the last cigarette (dose of nicotine),peak during the first few days of abstinence (when smokers trying to quit are most likely to relapse),and mostly subside within a few weeks. Another study of cognitive impairment,using four complex cognitive tasks during withdrawal from smoking in heavy smokers,ex-smokers,and those who had never smoked,assessed ability to perform those tasks; smokers with 12 hours of abstinence had the worst scores on the tasks. Another symptom associated with withdrawal is craving for cigarettes. Craving is strongly related to the degree of nicotine dependence. Craving may last 6 months which is longer than some of the other symptoms associated with tobacco withdrawal. Craving is a major obstacle to cessation and together with other indicators of nicotine de- Figure 1 pendence is strongly related to relapse,with the Cognitive Performance and an majority of smokers who attempt to quit relapsing Electrophysiological Measure of Brain Function within the first week of cessation. during Smoking and Abstinence. Although the foregoing are universal,albeit with some variation among individuals,some withdrawal symptoms are unique to individuals with specific characteristics. Smokers with a history of prompts to smoke. At the individual level,the major depression,for example,are at some risk of smoker may associate a cup of coffee,the end of a having another depressive episode during the cessa- meal,or watching television as a prompt to light a tion process. Smokers with comorbid disorders such cigarette. Socially,being with friends or family as alcoholism or illicit substance abuse are likely to members who smoke represents other cues to have more severe withdrawal symptoms as they at- smoke,while presence in a situation where smoking tempt to address more than one dependency. is not allowed may result in powerful negative feel- The withdrawal syndrome is undoubtedly biologically based; however,behavioral factors have a ings about smoking cessation. Environmental stim- strong influence on smoking cessation. Cigarette uli—being in bars or other places where the preva- smoking involves a number of rituals that become lence of smoking is high—are likely to reinforce the ingrained into the smoker’s daily life,resulting in smoker’s desire to smoke. Exposure to any of the numerous individual,social,and environmental cues to smoke may result in relapse. 1350 WITHDRAWAL: Nicotine (Tobacco)

TREATMENT OF NICOTINE not attained; group support,where individuals sup- WITHDRAWAL SYMPTOMS port each other in their quit attempts; and cognitive restructuring,where smokers are taught to think Two pharmacologic approaches,nicotine re- differently about smoking and cigarettes. Other placement therapy and drugs to manage symptoms components include relaxation exercises,coping associated with withdrawal,have been taken to tactics,visualization and addressing of tempting reduce nicotine withdrawal symptoms. In addition, situations,simple messages to deal with withdrawal behavioral approaches for withdrawal have been symptoms (e.g.,deep breathing,delay so the urge tested. will pass,drink water,do something else),and Nicotine replacement therapy. The purpose stimulus control (e.g.,getting rid of ashtrays,hav- of nicotine replacement is to substitute a safer and ing a smoke-free home). Multicomponent behav- controllable form of nicotine to the smoker to aid in ioral programs have had much success in helping cessation. Although nicotine replacement delivery smokers achieve cessation. Much research suggests systems vary,all attempt to reduce the amount of that nicotine replacement or pharmacologic ap- nicotine available during cessation so that an indi- proaches without a behavioral component have sig- vidual is weaned from nicotine addiction. Two nic- nificantly lower success rates than those with a otine replacement therapies are available over-the- behavioral component. counter: nicotine polacrilex gum and the transdermal nicotine patch. Two other delivery systems are available through prescriptions: an oral SUMMARY nicotine inhalation system and a nasal nicotine Nicotine is a very addictive drug that affects the spray. The effectiveness of each of the systems has central nervous system. Its use results in tolerance been well-established in randomized,controlled and dependence,so that the user feels most normal trials. when using tobacco. A clear nicotine withdrawal Symptom treatment. A number of drug ther- syndrome is known; smokers attempting cessation apies have been approved to alleviate or reduce may have dysphoria,insomnia,irritability,anxiety, some of the discomfort that accompanies smoking difficulty concentrating,restlessness,decreased cessation. The best known is bupropion (Zyban), heart rate,and increased appetite. Further,cogni- which is effective as an antidepressant. Bupriopion, tive ability is somewhat impaired during cessation, however,is also effective in smokers who have no strong craving for the drug is present,and powerful history of depression; thus,other factors may be behavioral cues make cessation difficult. New ap- involved in the success of this drug in smoking proaches to the withdrawal syndrome include the cessation. Another antidepressant,nortriptyline, administration of nicotine in a safer delivery system has also been shown to be useful for smoking cessa- that can be tapered over time,and drugs to counter tion. Clonidine,originally used to treat hyperten- the unpleasant symptoms of withdrawal. Along sion,appears to be modestly effective in blocking with behavioral treatment,such pharmacologic the cravings for nicotine,especially in women. tools may assist the smoker in achieving cessation. Other pharmacologic therapies are being tested for their value in ameliorating the withdrawal symp- BIBLIOGRAPHY toms of cessation. These include mecamylamine, which is thought to block the reinforcing action of AMERICAN PSYCHIATRIC ASSOCIATION (1994). Diagnostic nicotine,and anxiolytics and benzodiazepines, and statistical manual of mental disorders, 4th ed. which generally lower stress and decrease anxiety. Washington,DC: American Psychiatric Association. Behavioral approaches. Behavioral ap- BALFOUR,D. J.,& R IDLEY,D. L. (2000). The effects of proaches for preventing relapse have a long history nicotine on neural pathways implicated in depression: of use in smoking cessation. Behavioral strategies A factor in nicotine addiction? Pharmacology, Bio- generally focus on the social reinforcers of smoking. chemistry, & Behavior, 66,79–85. The most effective behavioral programs are those BENOWITZ,N. L. (1999). Nicotine addiction. Primary that have multiple components. Various behavioral Care: Clinics in Office Practice, 26,611–631. strategies include contracting to quit,with the GHATAN,P. H.,I NGVAR,M.,E RIKSSON L.,S TONE- smoker making a monetary donation if success is ELANDER,S.,S ERRANDER,M.,E KBERG,K.,& WITHDRAWAL: Nonabused Drugs 1351

WHAREN, J. (1998). Cerebral effects of nicotine dur- Nonabused Drugs Although drug with- ing cognition in smokers and non-smokers. Psycho- drawal is often considered synonymous with mat- pharmacology, 136,179–189. ters relating to drug abuse,a number of drugs HALL,S. M.,R EUS,V. I.,M UN˜ OZ,R. F.,S EES,K. L., which have no abuse potential and are prescribed HUMFLEET,G.,H ARTZ,D. T.,F REDERICK,S.,& T RIF- for medical illness are associated with clear symp- FLEMAN,E. (1998). Nortriptyline and cognitive-be- toms of withdrawal when their use is abruptly dis- havioral therapy in the treatment of cigarette smok- continued. The symptoms do not necessarily indi- ing. Archives of General Psychiatry, 55,683–690. cate drug dependence,a syndrome that has several HENNINGFIELD,J. E. (1995). Nicotine medications for features,including tolerance,inability to control smoking cessation. New England Journal of Medicine, drug use,and continued drug use despite deleteri- 333,1196–1203. ous effects. HUGHES,J. R.,G OLDSTEIN,M. G.,H URT,R. D.,& S HIF- FMAN,S. (1999). Recent advances in the phar- CARDIOVASCULAR DRUGS macotherapy of smoking. Journal of the American Beta-Adrenergic Blockers. These drugs are Medical Association, 281,72–76. taken by many people to treat hypertension (high SNYDER,F. R.,D AVIS,F. C.,& H ENNINGFIELD,J. E. blood pressure),angina pectoris (chest pain from (1989). The tobacco withdrawal syndrome: Perform- heart muscle deprived of oxygen),heart arrhyth- ance assessed on a computerized test battery. Drug mias following heart attack,and for migraine head- and Alcohol Dependence, 23,259–266. ache. The mechanism for each of these effects is SZIRAKI,I.,S ERSHEN,H.,B ENUCK,M.,L IPOVAC,M., related to the drug occupying the beta-adrenergic HASHIM,A.,C OOPER,T. B.,& L AJTHA,A. (1999). The receptors in the blood vessels and the heart. When a effect of cotinine on nicotine- and cocaine-induced patient abruptly stops taking a beta blocker,par- dopamine release in the nucleus accumbens. Neuro- ticularly when angina pectoris is the symptom be- chemical Research, 24,1471–1478. ing treated,a marked increase in the frequency U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES and/or severity of angina pectoris may occur. This (1988). The health consequences of smoking. Nic- occurs within the first few days of discontinuing the otine addiction. A report of the surgeon general. U.S. beta blocker; it may be prevented by slowly de- Department of Health and Human Services,Public creasing the drug dose over several days before Health Service,Centers for Disease Control,Office on completely stopping the drug. The discontinuation Smoking and Health. DHHS Publication No. symptom is probably related to an increased sensi- (CDC)88-8406. tivity of the beta receptor for the body’s own hor- U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. mones NOREPINEPHRINE and epinephrine,when its (1989). Reducing the health consequences of smok- antagonist,the beta blocker,is suddenly removed. ing. 25 years of progress. A report of the surgeon The withdrawal syndrome disappears in a few general. U.S. Department of Health and Human Ser- days,consistent with the time required for beta- vices,Public Health Service,Centers for Disease Con- adrenegic receptor reregulation. trol,Center for Chronic Disease Prevention and Clonidine. This drug is used for hypertension Health Promotion,Office on Smoking and Health. and to treat withdrawal from opiate narcotics. Its DHHS Publication No. (CDC)89-8411. mechanism of effect is stimulation of alpha(type U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2)-adrenergic receptors in the central nervous sys- (1990). The health benefits of smoking cessation. A tem,which results in decreased stimulation of report of the surgeon general. U.S. Department of nerves that release norepinephrine and epinephrine Health and Human Services,Public Health Service, in blood vessels. When CLONIDINE is abruptly Centers for Disease Control,Center for Chronic Dis- stopped,blood pressure increases to well above ease Prevention and Health Promotion,Office on baseline levels and may become dangerously high. Smoking and Health. DHHS Publication No. This occurs within one to two days after stopping (CDC)90-8416. the drug and is prevented by slowly (over several JACK E. HENNINGFIELD days) decreasing the drug dose before stopping it LESLIE M. SCHUTT completely. This may be due to a ‘‘rebound’’ over- REVISED BY BETI THOMPSON stimulation of norepinephrine and epinephrine re- 1352 WITHDRAWAL: Nonabused Drugs leasing nerves in blood vessels. This rebound hy- as can such affective symptoms as irritability and pertension disappears within a few days,again low mood. Symptoms usually start a few days after consistent with the time required for alpha-adren- termination of the antidepressant and continue ergic receptor reregulation. anywhere between one day and three weeks. The NitroglycerinandOther Nitrates. These mechanism of withdrawal may result from drugs are taken to treat angina pectoris. They cause up-regulation and increased sensitivity of the mus- the relaxation of blood vessels by the activation of carinic receptor,which is blocked by these drugs. an intracellular enzyme,guanylyl cyclase,which During chronic heterocyclic-antidepressant treat- catalyzes formation of cyclic GMP (guanosine moment,muscarinic-receptor sensitivity increases. nophosphate). The coronary arteries (blood vessels When receptor blockade is suddenly stopped,over- which supply heart muscles) relax when exposed to activity of these receptors in the digestive tract and nitrates. If the coronary arteries are blocked by brain causes the withdrawal symptoms. atherosclerosis,causing insufficient blood supply to Withdrawal symptoms of a class of antidepres- the heart,angina pectoris can occur. Relaxation of sants known as selective serotonin reuptake inhibi- these arteries improves blood supply to the heart tors (SSRIs) can be particularly deceptive and and the chest pain rapidly disappears. When ni- therefore problematic because some of the symp- trates are taken continuously for relief of chest toms are like those an individual experiences with a pain,then abruptly discontinued,rebound angina relapse of depression. In such instances,individuals pectoris which is more frequent or more severe than may be at risk of being prescribed even more anti- the angina experienced pretreatment may occur. depressants. This cycle of drug treatment is a sig- This begins within a few hours of the last nitrate nificant problem,especially since many govern- dose and in a time course consistent with the me- ment agencies have stepped up efforts to treat tabolism and removal of the nitrate drug from the depression and managed care plans are increas- body. If the nitrate dose is slowly decreased before ingly turning to antidepressants as a treatment for discontinuation,the rebound angina may be pre- depression. However,SSRIs have several distinct vented. The mechanism for this withdrawal syn- discontinuation symptoms,including dizziness and drome is not certain,however,it is probably related such sensory abnormalities as electric shocklike to loss of the chronic activation of guanyl cyclase sensations,numbness,and paraesthesia. The during nitrate therapy and abnormal regulation of symptoms typically go away the day after antide- the contractile apparatus in the blood vessel mus- pressant treatment has resumed,unlike a true de- cle,leading it to have rebound contraction. pressive relapse,which takes longer. Therefore, with care,a misdiagnosis of a relapse of a psychiatric illness can often be avoided. In addition,to NEUROPSYCHOPHARMACOLOGICAL reduce the risk of withdrawal symptoms,some DRUGS physicians have recommended that antidepressants Antidepressants. These drugs are used to be gradually reduced over a four week period treat major depressive illnesses; therefore they are rather than abruptly discontinued. frequently administered daily for periods of weeks Monoamine Oxidase Inhibitor (MAOI) antide- or months. Abrupt discontinuation of any of the pressants drugs interfere with the enzymatic break- major classes of ANTIDEPRESSANTS may result in down of NEUROTRANSMITTERS (such as norepineph- discontinuation reactions. Antidepressants vary in rine) in the brain. Sudden discontinuation after their ability to cause reactions,and reactions are high chronic dosing has been associated with psy- more common after abrupt discontinuation and chosis and delirium—consisting of visual halluci- longer courses of treatment. Common symptoms nations as well as mental confusion. Milder symp- include gastrointestinal problems like nausea,ab- toms consisting of anxiety,vivid dreaming,or dominal pain,and diarrhea. In addition,some pa- nightmares may also occur. The exact mechanism tients complain of a flulike illness consisting of of withdrawal has not been well studied,but it may weakness,chills,fatigue,headaches,and muscle relate to the way nerve cells regulate the release of aches. Central nervous system dysfunction charac- neurotransmitters in the brain. Presynaptic recep- terized by difficulty falling asleep,anxiety,vivid tors serve to provide a message to nerve cells about dreams or nightmares,or jitteriness can also occur, how much neurotransmitter is present in the WITHDRAWAL: Nonabused Drugs 1353 synapse—the space between two nerve cells where baclofen inhibits excitatory neural pathways, messages,in the form of neurotransmitters,flow which are modulated by GABA and which ulti- between cells. When activated,these types of recep- mately stimulate skeletal muscles to contract. This tors (present on the surface of the nerve cell releas- is a rather selective effect as there are two types of ing the message) inhibit any further release of neu- GABA receptors and pathways,GABA-A and rotransmitters. As a result of treatment with MAOI, GABA-B,of which baclofen only acts on GABA-B decreases in the number of presynaptic receptors receptors. When baclofen is used to treat muscle occur,resulting in larger amounts of neurotrans- spasm,the excitatory pathways of the spine are mitter being released before the cell shuts down chronically modulated and inhibited. When release. The increase in the amount of neurotrans- baclofen is abruptly discontinued,this inhibition is mitter may result in withdrawal symptoms that released and,within a few hours as is consistent abate over a period of days after discontinuation. with the rate of disappearance of baclofen,the ex- Major Tranquilizers. NEUROLEPTIC agents citatory pathways rebound—probably due to a are commonly used in psychiatric practice for the transient unregulated state. The symptoms experi- treatment of psychotic disorders such as schizo- enced by a person suddenly discontinuing baclofen phrenia. These agents all block brain dopaminergic may include auditory and visual hallucinations,se- receptors—the basis for their effectiveness in treat- vere anxiety,increased heart rate and blood pres- ing psychotic illness. These agents also inhibit eme- sure,and generalized seizures. Such clinical symp- sis (vomiting),which is caused by dopaminergic toms are consistent with the impaired modulation blockade in the brain as it affects the perception of neural-excitatory pathways. When baclofen dos- and initiation of vomiting. Chronic blockade results age is gradually reduced before discontinuation, in increased numbers of these receptors. The these symptoms either do not occur or are attenu- abrupt discontinuation of this class of drugs results ated,indicating that the inhibitory/excitatory-neu- in nausea,vomiting,and headaches. The antipsy- ral-pathway balance,which has been disturbed by chotic and antiparkinsonian effects of neuroleptics the excessive inhibitory modulus of baclofen,has are also still present for a prolonged period. Ac- the capacity to reregulate over a few days. cording to some research,it is not known whether Corticosteroids. The drug prednisone will be the prolonged effects of neuroleptic drugs in hu- discussed specifically; however,the biological mans are due to the continued presence of drug in changes that result in withdrawal phenomena after brain tissue or to long-lasting,drug-induced physi- discontinuation of long-term prednisone treatment ologic changes. hold for all members of the glucocorticoid group. Clozapine is in a class of atypical antipsychotic When,for example,a significant dose (5–10 mg drugs associated with discontinuation symptoms. daily) of prednisone is taken for a period of several Although atypical antipsychotics may be different weeks,a series of feedback regulatory events occurs from other neuroleptic drugs,there are also signifi- resulting in the patient becoming functionally cant differences among these drugs in their effects adrenally insufficient. Specifically,in mimicking on the receptors of the central nervous system. Cloz- the endogenous corticosterone cortisol,prednisone apine interacts with a wide range of neurotransmit- signals the pituitary gland to stop the synthesis and ter receptors,especially serotonin receptors. Com- release of the adrenocorticotrophic hormone mon discontinuation symptoms of clozapine include (ACTH) and,perhaps,the hypothalamus to stop delusions,hallucinations,hostility,and paranoia. the release of the corticotropin-releasing hormone The underlying mechanism of these symptoms is (CRH). ACTH release from the pituitary,which thought to be cholinergic supersensitivity. normally stimulates the adrenal glands to produce corticosterones and which is modulated by the hypothalamic CRH,is blocked by the drug pred- OTHER DRUGS nisone when ingested in the above dose or greater. Baclofen. As a muscle relaxant,this drug is Not only does adrenal production of cortisol de- used to treat muscle spasticity associated with cer- crease but also the adrenal glands atrophy. tain paralytic states. It acts as an agonist (mimic) of When prednisone therapy is abruptly discontin- the inhibitory neurotransmitter in the spinal cord, ued,the atrophic adrenal glands no longer respond GAMMA-AMINOBUTYRIC ACID (GABA). Therefore to ACTH stimulation,so the patient has symptoms 1354 WITHDRAWAL: Nonabused Drugs of adrenal insufficiency. Clinically,this is mani- continuation of a drug to which the system has fested by fatigue,weakness,electrolyte imbalance, adapted results in a period of disequilibrium be- and the lack of many bodily responses to stress. If tween the affected messaging systems. The dis- an individual remains in this state for more than a turbed physiology is expressed by specific with- few hours,severe illness and death can be expected. drawal symptoms. When the adrenal glands become atrophic during long-term prednisone treatment,if the prednisone (SEE ALSO: Anabolic Steroids; Withdrawal: Alco- is to be discontinued,it must be done with slowly hol ) decreasing doses over many weeks to permit the adrenal glands sufficient time to regrow to their BIBLIOGRAPHY normal size under the influence of ACTH stimulation and to have sufficient stores of the body’s own BERECZ,R.; G LAUB,T.; K ELLERMANN,M.; DE LA RUBIA, cortisol to respond to stress in a physiologically A.; LLERENA,A.; & D EGRELL,I. (2000) Clozapine appropriate manner. withdrawal symptoms after change to sertindole in a schizophrenic patient. Pharmacopsychiatry, 33,42– COMPARISONS WITH DRUGS 44. OF ABUSE BYYNY,R. L. (1976). Withdrawal from glucocorticoid therapy. New England Journal of Medicine, 295,30– ALCOHOL is one of the most common drugs of 32. abuse. If alcohol withdrawal is used as a basis for CEDERBAUM,J. M.,& S CHLEIFER,L. S. (1990). Drugs for comparison,marked similarity in effect is noted Parkinson’s disease,spasticity,and acute muscle when considering the cardiovascular drugs (beta- spasms. In A. G. Goodman et al. (Eds.), Goodman & blockers,clonidine,nitrates) and baclofen. Alcohol, Gilman’s the pharmacological basis of therapeutics, a nonspecific central nervous system depressant, 8th ed. New York: Pergamon. leads to an ill-defined reregulated state,allowing DURST,R; T EITELBAUM,A; K ATZ,G;&KNOBLER,HY habituated individuals some level of function during (1999). Withdrawal from clozapine: The ‘‘rebound their chronic alcohol-induced depressive state. phenomenon.’’ Israel Journal of Psychiatry and Re- Abrupt cessation of alcohol consumption results in lated Sciences, 36,122–128. loss of the depressive state,with a rebound state of psychic and physical excitation. This is not unlike GOLDSTEIN,J. M. (1999). Quetiapine fumarate (Seroquel the cardiovascular drugs and baclofen; there,the (R)): A new atypical antipsychotic. Drugs of Today, withdrawal syndrome is the clinical manifestation 35,193–210. of a neural- or cellular-regulatory system that has GOUDIE,A. J; S MITH,J. A.; R OBERTSON,A; & C AVANAGH, reached a new homeostatic state under the influence C. (1999). Clozapine as a drug of dependence. Psy- of the drug and the sudden drug removal leaves chopharmacology, 142,369–374. insufficient time for physiological reregulation. In HADDAD,P. (1999). Do antidepressants have any poten- the case of corticosteroids,the reverse of this mecha- tial to cause addiction? Journal of Psychopharmaco- nism occurs. Here,the physiological regulation logy, 13,300–307. which has occurred during prednisone therapy leads HADDAD,P.; L EJOYEUX,M.; & Y OUNG,A. (1998) Antide- to loss of the capacity to have a physiological re- pressant discontinuation reactions: are preventable sponse,instead of an over-response. and simple to treat. British Medical Journal, 316, Human physiology is characterized by the coor- 1105. dinated and finely tuned operation of multiple mes- HOUSTON,M. C.,& H ODGE,R. (1988). Beta-adrenergic saging systems,exhibiting both positive and nega- blocker withdrawal syndromes in hypertension and tive feedback regulation,with multiple levels of other cardiovascular diseases. American Heart Jour- control. All the drugs mentioned exert both their nal, 116,515–523. desired and undesired effects by interfering with KOTLYAR,M; G OLDING,M; B REWER,EDWIN R.; & CARSON, these systems. In the drug-treated individual,ho- S. W. (1999). Possible nefazodone withdrawal syn- meostasis is maintained by counteracting some of drome. American Jouranl of Psychiatry, 156,1117. the drug effects at the cellular level. Such adapta- LEVIN,A. A. (1998). Antidepressant dependency. tion is not without cost. The sudden dis- HealthFacts, 23,2. WOMEN AND SUBSTANCE ABUSE 1355

PARKER,M.,& A TKINSON,J. (1982). Withdrawal syn- dence of increased female alcoholism or problem dromes following cessation of treatment with antihy- drinking. Changing female drinking patterns have pertensive drugs. General Pharmacology, 13,79–85. resulted more in a reduction in female abstainers SHATAN,C. (1966). Withdrawal symptoms after abrupt than an increase in problem drinkers. Nevertheless, termination of imipramine. Canadian Psychiatric As- there is some evidence for convergence in the sociation Journal, 2,150–157. youngest cohorts,with the smallest sex differences TOLLEFSON,G. D.; D ELLVA,M. A.; M ATTLER,C. A; K ANE, in heavy drinking being for youths aged twelve to J. M.; WIRSHING,D. A.; & K INON,B. J. (1999). Con- seventeen (2 percent of boys and 1 percent of girls trolled,double-blind investigation of the clozapine in 1993). Among adults aged thirty-five and older, discontinuation symptoms with conversion to either men are eight times as likely as women to be heavy olanzapine or placebo. Journal of Clinical Psycho- drinkers (8 percent compared with 1 percent). pharmacology, 19,435–443. There is greater evidence of sex-role conver- YOUNG,A.,& H ADDAD,P. (2000). Discontinuation symp- gence in TOBACCO use. In 1955,52 percent of adult toms and psychotropic drugs; Letter to the Editor. men smoked,compared with 25 percent of adult The Lancet, 355,1184. women. Since then,the proportion of men who DARRELL R. ABERNETHY smoke has decreased markedly while rates among PAOLO DEPETRILLO women have held fairly steady. Among adults aged REVISED BY PATRICIA OHLENROTH 35 and older in 1993,27 percent of men and 21 percent of women were current smokers. Among youths aged twelve to seventeen,girls have sur- WOMEN AND SUBSTANCE ABUSE passed boys in their rates of current cigarette use There are gender differences in the prevalence of (10 percent of girls compared with 9 percent of substance abuse. boys in 1993). Because boys are more likely than girls to use smokeless tobacco products,however, ALCOHOL AND TOBACCO USE their overall rates of nicotine addiction still exceed girls’ rates. General population studies indicate that fewer Biener (1987) reviews factors that have contrib- women drink than men,and women who do drink uted to the convergence in male and female smok- consume less alcohol than men. Of the estimated 15 ing. Product developments such as filtered and low- million alcohol-abusing or alcohol-dependent indi- tar cigarettes have made smoking easier for women viduals in the United States,fewer than one-third to tolerate physically. Tobacco companies have tar- ATIONAL OUSEHOLD are women. In the 1993 N H geted ADVERTISING to make smoking attractive to SURVEY on Drug Abuse (NHSDA),57 percent of young women. Once tobacco use is initiated, men reported they drank alcoholic beverages in the women are less likely than men to quit smoking previous month,compared with 43 percent of and,compared with men who have quit smoking, women. The NHSDA defines heavy alcohol use as 5 women quitters are more likely to relapse. or more drinks per day on each of 5 or more days in The convergence in male and female smoking the past 30 days. By this definition,in 1993 men rates has been accompanied by a convergence in were much more likely than women to be heavy smoking-related health problems. For example, drinkers (10 and 2 percent,respectively). lung cancer deaths among women have increased It has been suggested that male and female sex markedly since the 1970s,and lung cancer now roles,and therefore drinking norms,have become surpasses breast cancer as the leading cause of more similar in recent years. Some sex-role changes CANCER deaths among women. that could increase opportunities for,and acceptability of,female drinking include greater female ILLICIT DRUG USE labor force participation,delayed marriage and childbearing,and more equitable sex-role atti- Males are far more likely than females to be tudes. According to this convergence thesis,greater arrested for possessing or selling illicit drugs. In sex-role equality may cause PROBLEM DRINKING 1992,for example,the Federal Bureau of Investi- and ALCOHOLISM to increase among women. How- gation reported that only 16 percent of those ar- ever,recent epidemiological data reveal little evi- rested for drug-abuse violations were female. At all 1356 WOMEN AND SUBSTANCE ABUSE ages,males are more likely than females to use Although these trends merited watching,such spec- illicit drugs. Gender differences are smallest among ulation was premature,given current evidence. adolescents aged twelve to seventeen and among adults aged thirty-five and older,and largest MEDICAL DRUG USE among young adults aged eighteen to thirty-four, In the 1970s feminist scholars drew attention to the age range in which illicit-drug use is most possible overmedication of women with PSYCHOAC- prevalent. In the 1993 NHSDA,11 percent of men, TIVE DRUGS. These early critiques derived from compared with 6 percent of women,aged twenty- content analyses of sex-stereotyped advertisements six to thirty-four reported they had used some illicit in medical publications. Most of the ads depicted drug in the previous month. Nineteen percent of woman patients,and survey research on represen- men and 8 percent of women reported current (i.e., tative populations confirmed that women were us- past month) illicit-drug use in 1993. Among both ing more prescription psychoactive drugs than were men and women,marijuana is the most frequently men. used illicit substance,with 16 percent of men and 6 Critics of these patterns are concerned that percent of women aged eighteen to twenty-five re- drugs are being used beyond traditional medical porting current use. psychiatric concepts of disease. For example,medi- COCAINE use has decreased since the mid-1980s, cal ads suggested prescribing TRANQUILIZERS and and is rare compared with marijuana use. Sex dif- ANTIDEPRESSANTS to alleviate normal life transi- ferences in regular cocaine use are small. In the tions,such as menopause,starting college,or a young adult age group,where use is most common, woman’s adult children moving out. It has been 1.7 percent of men and 1.4 percent of women suggested that prescribing psychoactive drugs is a reported cocaine use in the past month. In 1993, subtle form of social control that diffuses or chan- among youths aged twelve to seventeen,boys and nels women’s discontent with limiting and in- girls were equally liken to report cocaine use in the equitable sex roles. past month (0.4 percent). Some of the prescription psychoactives have Prior to the HARRISON NARCOTICS ACT of 1914, dangerous side effects and a high potential for pro- the typical OPIATE addict in the United States was a white,middle-aged,middle-class housewife who ducing dependency. Further,since women also use VER-THE-COUNTER medications and had become addicted to medically prescribed drugs more O women’s alcohol problems are often undetected by or nonprescription PATENT MEDICINES. Following criminalization of most opiate use through the Har- physicians,use of prescription psychoactive drugs rison Act and subsequent legislation and court in- may make women especially vulnerable to adverse terpretations,overall levels of opiate use declined drug interactions. Alcohol in combination with other substances is the most frequent cause of dramatically. When HEROIN addiction reemerged RUG ABUSE as a social problem in the 1950s and 1960s,the emergency-room episodes in the D WARNING NETWORK (DAWN) system. Although typical opiate addict was a nonwhite urban male women drink less and are less likely to use illicit from a lower socioeconomic class. Although the drugs,they have equaled or exceeded men in drug- VIETNAM war exposed a broader spectrum of young American men to heroin use,and although many related emergency room episodes since the mid- servicemen tried opiates and even became addicted 1980s. This is because more women needed emer- in Vietnam,most were able to discontinue use gency treatment related to tranquilizer,sedative, when they returned to the United States. and nonnarcotic analgesic use. In the 1970s and 1980s,heroin use decreased GENDER DIFFERENCES IN THE and became quite rare in the United States. In 1993, ETIOLOGY OF SUBSTANCE ABUSE only about one in 1,000 Americans aged twelve and older reported use of heroin in the past year,and the Studies of ADOLESCENTS generally find similar majority of users were men. An increase in drug correlates of substance abuse among both boys and seizures,arrests,and heroin-related emergency girls. The strongest predictor of adolescent alcohol, room episodes in the early 1990s led to assertions tobacco,and illicit-drug use is having friends who that heroin was making a comeback and that use alcohol,tobacco,and drugs. Other factors that women would be especially vulnerable to addiction. predict substance abuse by boys and girls include WOMEN AND SUBSTANCE ABUSE 1357 parental substance abuse,poor academic perform- is grounded both in biological differences and in ance,and low commitment to educational pursuits. social-role expectations. Researchers,however,have identified some gen- From a biological standpoint,it is frequently der differences in the development of alcohol and noted that the lower ratio of water to total body drug problems. Relationship issues are particularly weight in women causes them to metabolize alcohol salient in the etiology of female substance abuse. For and drugs differently than men. Even when body example,alcoholism in women is more strongly weight is controlled,given equivalent alcohol con- correlated with a family history of drinking prob- sumed,women pass more alcohol into the blood- lems than is alcoholism in men. Girls and women are stream and reach higher peak BLOOD ALCOHOL likely to be introduced to alcohol or illicit drugs by a CONCENTRATIONS than men,in part because of boyfriend or spouse,and female alcohol or drug differences in enzyme activity in the intestinal wall. dependence frequently develops in a relationship Drugs such as marijuana that are deposited in body with an alcohol- or drug-dependent male partner. fat may be slower to clear in women than in men. Alcohol and drug abuse are more often associated Slow clearance rates create a potential for cumula- with DEPRESSION in girls and women compared with tive toxicity and adverse drug and alcohol interac- males,but it is not clear whether depression is more tions. likely to cause female substance abuse or is a more The behavioral telescoping of women’s uncon- typical consequence of substance abuse among girls trolled drinking and drug use is paralleled by a and women. Women in treatment for substance telescoping of some physical health consequences abuse are more likely than men to say their problem of alcohol and drug use. Alcoholic liver disease pro- drinking or drug abuse developed after a life crisis or gresses more rapidly in women compared with tragedy,such as the death of a family member. Also, men. Women also seem to be more prone to alco- a sizable proportion of women in treatment report hol-related brain damage. They show physical histories of sexual abuse. Men are more likely to say brain abnormalities after a shorter drinking history their problem drinking or drug abuse developed out and at lower peak alcohol consumption. Women of social or recreational use. also exhibit cognitive deficits on psychological tests Some believe these different attributions and of memory,speech,and perceptual accuracy with a recollections reflect genuine sex differences in the shorter drinking history than that of men. etiology of substance abuse. Others caution,how- Women diagnosed as alcoholic have very high ever,that the greater stigma attached to female mortality rates relative to both the general popula- substance abuse may motivate women to develop tion of women and to alcoholic men. A follow-up an explanation for their problem drinking or drug study of alcoholic women in St. Louis,found that, use,and that personal crises and emotional diffi- 11 years after treatment,they had lost an average culties serve as socially acceptable reasons. of 15 years from their expected life span. Another study of 1,000 female and 4,000 male alcoholics in The course of problem drinking and drug addic- Sweden found the excess mortality was higher for tion varies by gender. Women entering treatment the women (5.2 times the expected rate) than for for alcoholism or drug abuse tend to have begun the men (3 times the expected rate). heavy drinking or drug use at a later age,on aver- Deaths due to drugs other than alcohol and to- age,compared with men entering treatment. The bacco are relatively uncommon among women. term ‘‘telescoping’’ has been used to describe a Men are far more likely than women to die from more rapid progression from controlled alcohol or drug use. The higher male death rates are largely drug use to alcohol and drug dependency in explained by males’ greater drug use rather than by women,compared with men. sex differences in vulnerability among drug users. In 1990,medical examiners in twenty-seven U.S. GENDER DIFFERENCES IN THE metropolitan areas reported 5,830 deaths involving CONSEQUENCES OF illicit and/ or legally obtained drugs. Of those who SUBSTANCE ABUSE died from drug-related causes (e.g.,O VERDOSE,ac- It is generally presumed that alcohol and drug cidental injury),71 percent were male. abuse will produce more deleterious consequences The HIV virus that causes AIDS is transmitted among women than among men. This expectation primarily via infected blood and semen. Sharing 1358 WOMEN AND SUBSTANCE ABUSE needles and having sexual relations with intrave- drug effects from other adverse conditions the nous (IV) drug users places both men and women mother may have experienced,such as poor nutri- at risk for contracting that incurable disease. Al- tion,acute or chronic illness,and inadequate pre- though most AIDS cases have resulted from trans- natal care. As currently practiced,prenatal drug- mission of HIV during intimate sexual contact be- use detection procedures raise important questions tween men, about 12,000 of the 43,000 people of fairness. Hospitals and clinics serving largely reported to have AIDS in 1990 were IV drug users. poor and minority patient populations are more Most of these AIDS cases involving IV drug use likely to detect prenatal substance abuse despite were male. When women contract AIDS,the most evidence that substance abuse occurs in all socio- common route of transmission is through their own economic categories. IV drug use or sexual contact with a partner who is The tendency of female problem drinking and an IV drug user. drug abuse to develop in a relationship with a sub- Women’s reproductive function increases alco- stance-abusing male partner may shield women hol- and drug-related health risks to themselves from some consequences of their substance abuse. and to their unborn children. Alcohol and drug For example,women alcoholics and addicts are less abuse are associated with numerous disorders of vulnerable to arrest if their partner procures drugs the female reproductive system,including breast for the couple or drives when they are intoxicated. cancer,amenorrhea,failure to ovulate,atrophy of On the other hand,substance-abusing partners in- the ovaries,miscarriage,and early menopause. crease some other risks for alcohol- and drug-de- Men also experience reproductive and sexual diffi- pendent women compared with men. Women with culties as a result of alcohol and drug abuse,includ- substance-abusing partners are vulnerable to doing impotence,low testosterone levels,testicular at- mestic VIOLENCE. Also,a substance-abusing part- rophy,breast enlargement,and diminished sexual ner can be an impediment to women’s seeking or interest. complying with alcohol and drug treatment. Infants born to women who used alcohol,to- Despite women’s biophysical vulnerability and bacco,or other drugs during P REGNANCY can expe- the stigma associated with female alcohol and drug rience numerous health problems,including low abuse,men are more likely than women to experi- birth weight,major congenital malformations,neu- ence some problems related to heavy drinking and rological problems,mental retardation,and with- illicit drug use. Substance abuse is more strongly drawal symptoms. Although substance abuse at related to intrapsychic problems among women, any time during pregnancy can cause birth defects, and to problems in social functioning (employment the very rapid cell division in the first weeks of difficulties,financial problems,unsafe driving,ar- embryonic development means the teratogenic ef- rest) among men. fects of alcohol and drugs are generally greatest These gender differences may be related to sex- early in pregnancy,before a woman even realizes role differences in drinking and drug use. Male she is pregnant. substance use is less socially controlled—occurring As the medical and social costs of prenatal alco- more often in recreational contexts,public places, hol and drug exposure become more apparent,so and all-male settings—whereas female substance does public pressure for action. Many advocate ter- use is more likely to occur in the home,with a male mination of parental rights in cases where a new- partner,and under medical auspices. Sex roles may born tests positive for drug or alcohol exposure. In also allow males to exercise less personal control some jurisdictions,mothers who used alcohol or while drinking or using drugs. For example,male drugs during pregnancy have been charged with episodes of intoxication are more often associated child abuse or delivering a controlled substance to a with rapid ingestion,blackouts,and A GGRESSION. minor. Critics of these policies charge that alcohol and drug screening will discourage substance- GENDER AND SUBSTANCE abusing women from obtaining necessary prenatal ABUSE TREATMENT care. Legally,it may be difficult to establish criminal intent if substance abuse occurred early in an Men outnumber women in drug and alcoholism unintended and unrecognized pregnancy. Further, treatment units. The 1991 National Drug and Alco- it is often difficult to causally disentangle alcohol or holism Treatment Unit Survey (NDATUS) found WOMEN’S CHRISTIAN TEMPERANCE UNION 1359

213,681 women in some type of treatment, com- BOYD,M. R.,& M ACKEY,M. C. (2000). Alienation from pared with 562,388 men (U.S. Department of self and others: The psychosocial problem of rural Health and Human Services,1992). Self-reports of alcoholic women. Archives of Psychiatric Nursing, 14, treatment experience indicate a somewhat smaller 134–141. sex difference. In the 1991 NHSDA,1.8 percent of CENTER FOR SUBSTANCE ABUSE PREVENTION. (2000). Al- males aged twelve and older reported they were cohol, Tobacco and Other Drugs (ATOD) Resource treated for substance abuse in the previous year, Guide for Lesbians, Gay Men, and Bisexuals. Rock- compared with 0.9 percent of females. The discrep- ville,MD: National Clearinghouse for Alcohol and ancy may occur because women are less likely to Drug Information. report informal help,such as pastoral counseling or FORD,J. A. (1999). Substance Abuse: A Strong Risk,Of- SELF-HELP groups,as T REATMENT. ten Overlooked. Window on Wellness, 3,Summer Among alcoholics and addicts,a greater per- 1999. Dayton,OH: Substance Abuse and Disability centage of women are parents,and among sub- Issues,Wright State University School of Medicine. stance-abusing parents,more women have child GAY,LESBIAN,BISEXUAL, AND TRANSGENDERED (GLBT) custody. Parenting considerations are a major bar- HEALTH. (2000). Substance Abuse. New York: GLBT rier to women seeking substance-abuse treatment. Health. Few residential treatment programs make provi- NATIONAL COUNCIL ON ALCOHOLISM AND DRUG DEPEN- sions for pregnant women or mothers. Many DENCE (NCADD). (2000). Use of Alcohol and Other women are unable to find caregivers for their chil- Drugs Among Women. New York: NCADD. dren if they enter residential treatment,and fear RIGOTTI,N. A.,L EE,J. E.,& W ECHSLER,H. (2000). US permanent loss of custody if their children enter the college students’ use of tobacco products: Results of a foster care system. national survey. Journal of the American Medical As- Substance-abuse treatment programs have been sociation, 284,699–705. geared more to the problems and needs of male SMITH,W. B.,& W EISNER,C. (2000). Women and alco- clients. Some contend that only sex-segregated hol problems: A critical analysis of the literature and treatment can meet the unique needs of female unanswered questions. Alcohol in Clinical Experi- clients. Even those advocating integrated programs mental Research, 24,1320–1321. acknowledge the need for greater attention to CYNTHIA ROBBINS women’s issues. In addition to parenting responsi- REVISED BY REBECCA J. FREY bilities,it is urged that treatment programs address women’s histories of physical and sexual abuse, domestic violence,and relationships with substance-abusing partners. Burman (1994) also sug- WOMEN’S CHRISTIAN TEMPERANCE The nineteenth century was a time of gests that treatment programs for women should UNION drastic changes in the way many Americans viewed emphasize skills such as problem solving,assertive- ALCOHOL. Early in the century,on average,U.S. ness,self-advocacy,and L IFE SKILLS (including parenting and job seeking). citizens each consumed approximately 7 gallons of alcohol annually,the equivalent of about 2.5 ounces of pure alcohol daily. Concern that the (SEE ALSO: Addicted Babies; Complications: Endo- crine and Reproductive Systems; Family Violence United States would turn into a ‘‘nation of drunk- and Substance Abuse; Gender and Complications ards’’ led to the TEMPERANCE MOVEMENT of the of Substance Abuse; Injecting Drug Users and HIV; early nineteenth century. This movement was Stress; Treatment; Vulnerability As Cause of Sub- loosely organized,consisting of the following distance Abuse) verse factions: (1) the neorepublicans,who were concerned with a host of problems that threatened the nation’s security; (2) temperance societies,such BIBLIOGRAPHY as the Washingtonians,which served as the fore- BEERS,M. H.,& B ERKOW,R. (Eds.) (1999). The Merck runners of modern-day self-help groups; and Manual of Diagnosis and Therapy,17th ed. (3) physicians,who came to view habitual drunk- Whitehouse Station,NJ: Merck Research Laborato- enness as a disease. The goals of these groups ries. varied; they ranged from helping habitual drunk- 1360 WOMEN’S CHRISTIAN TEMPERANCE UNION ards,to discouraging the use of alcoholic beverages, to advocating the prohibition of alcoholic beverages. This first wave of temperance activists met with some success—thirteen states passed prohibition laws by 1855,and average alcohol consumption rates dropped to less than 3 gallons per person annually—but this was stopped by the growing national concern surrounding the approaching Civil War. Although the role of women was nearly nonexistent during this first temperance movement,the early movement set the stage for the post- Civil War temperance movement,in which women played a crucial part. The years following the Civil War were a somewhat chaotic time. With the onset of the urban- industrial revolution and the concomitant changes witnessed in postbellum America,many people sought what Lender and Martin (1982,p. 92) term ‘‘a search for order.’’ This search found a home in various social-reform movements. Broad- based reform movements attacked a number of issues thought to threaten American society,in- Frances Willard, the most influential leader of cluding education reform,women’s rights,and the temperance movement, served as president of intemperance. the WCTU from 1879 until her death in 1898. Aaron and Musto (1981) refer to this period as (The Library of Congress) the second great prohibition wave. Many local temperance societies survived the Civil War,as did the American Temperance Union. In 1869,the Na- At the same time,a growing number of physi- tional Prohibition party was formed. This group cians and temperance workers were coming to re- supported the abolition of alcohol and recruited gard habitual drunkenness as a disease. At the core women into the anti-liquor fight. The National Pro- of the conception of this disease was its inherently hibition party advocated complete and unrestricted progressive nature. Moderate drinking inevitably suffrage for women,and their enlistment of women led to addiction,according to temperance workers, into the temperance movement marked the first who proposed that as long as liquor was available public involvement of women in the temperance to entice people to drink,and as long as moderate effort. drinkers were around to act as models,then there The post-Civil War Progressive movement also would be drunkards. Increasingly,the blame for influenced the issue of temperance. The Progres- such addiction to alcohol was placed less on the sives believed that alcohol was ‘‘the enemy of in- individual and more on the society that permitted dustrial efficiency,a threat to the working of demo- the sale of liquor and condoned drinking. cratic government,the abettor of poverty and Some of the other factors that contributed to the disease’’ (Bordin,1981,p. xvi). To the Progres- milieu in which the women’s temperance move- sives,temperance reform was a means for con- ment developed included better education for fronting genuine social problems. Business leaders women,fewer children to care for,and the growing increasingly came to view the use of alcohol as urbanization of America. As more household appli- incongruous with the new technological society that ances became available and fewer women had to America was becoming. Alcohol symbolized waste- work around the clock at home or on the farm,they fulness,rampant pluralism,individualism,and po- gained more leisure time. In addition,women came tential social disorder. to be viewed as the protectors of the home—while, WOMEN’S CHRISTIAN TEMPERANCE UNION 1361 increasingly,alcohol was seen as a threat to the the organization to (1) strongly promote the intro- security of the home. These factors,in combination duction of temperance education in both Sunday with an increased middle class and better commu- schools and public schools; (2) continue to use the nications,set the stage for the first mass movement evangelical methods,mass meetings,and prayer of women into U.S. politics. services that had been successful during their cru- sades; (3) urge the newspapers to report on their DIO LEWIS AND THE activities; and (4) distribute literature informing WOMEN’S CRUSADE people of their cause. Although these first program commitments were later expanded,the conven- Ironically,the direct origins of the movement in tion’s first set of resolutions provided the direction which women gained entry into the political arena the WCTU would initially follow. can be traced back to a man—Dio Lewis. By the 1874–1879. Under the leadership of Annie 1870s,Lewis,a trained homeopathic physician, Wittenmeyer,the primary commitment of the had given up his practice of medicine to embark on WCTU was to gospel temperance. Wittenmeyer a career as an educator and lecturer. In December contended that the WCTU program should stress 1873,Lewis’s lecture circuit included the cities and personal reform of the drunkard and of the whole small towns of Ohio and New York. In each of liquor industry by moral suasion. She supported them,he agreed to deliver an additional lecture as conversion to Christianity,religious commitment, well as his scheduled talk related to women’s is- acknowledgment of sin,and willingness to abandon sues—the topic of his extra speech was the duty of evil ways as methods to reform those who drank. Christian women in temperance work. As an imme- She shied away from seeking out legislative man- diate result of his temperance lectures,women in dates as the solution to intemperance,however,and each of these cities organized and marched on intentionally distanced herself from the women’s saloons and liquor distributors. Praying and sing- suffrage movement; she feared possible repercus- ing hymns,the women were able to convince many sions for women in the home,should they campaign proprietors of alcohol establishments to pledge for the right to vote. themselves to stop selling liquor. Although Wittenmeyer was instrumental in the This grass-roots movement,which came to be early success of the WCTU,Frances Willard is known as the Women’s Crusade,quickly moved recognized as the most influential leader of the through Ohio and into neighboring states. Typi- women’s temperance movement. Willard was cho- cally,the women of a community would call a sen to be secretary at the first convention. Her views meeting eliciting support from other women. After were often more radical than those of Wittenmeyer, praying over their cause,they would organize their particularly regarding women’s rights. In 1879,she efforts,which included asking local ministers to was elected president of the WCTU and served in preach on the topic of temperance. They also that role until her death in 1898. Twentieth-cen- sought pledges of support from local political lead- tury observers of the women’s temperance move- ers. Finally,they would take to the streets,march- ment may be more familiar with the name of Carrie ing on distributors of liquor as they attempted to Nation,who was known for raiding saloons armed persuade them to cease their sales of alcohol. with axes and hatchets; however,militant individuals such as she constitute a small fringe element of HISTORY the WCTU. During the latter part of the nineteenth century,the true spirit of the WCTU was embodied By November 1874,the Women’s Crusade had in the person of Frances Willard. grown to the point where a national convention was 1879–1898. While Wittenmeyer’s primary called. Sixteen states were represented at this con- commitment was to moral suasion,from the begin- vention,out of which the Woman’s Christian Tem- ning of Willard’s involvement in the WCTU, perance Union (WCTU) emerged. Annie Wit- women’s rights commanded her deeper loyalty. tenmeyer was named the first president of the This commitment would be seen in the direction WCTU,and a platform of action was agreed upon the WCTU would take after 1879 (and was even including the principle of total abstinence for evident while Willard served as secretary,as she WCTU members. Other plans involved committing subtly pushed for commitment to broader political 1362 WOMEN’S CHRISTIAN TEMPERANCE UNION programs). In 1876,Willard had introduced the was willing to go to support the prohibition cause. concept of ‘‘home protection’’ to the WCTU. Build- By the late 1880s,however,she was committed to ing on earlier arguments that made use of women’s broader societal changes. Willard’s strongest com- traditional roles within the home and the need to mitment remained to women’s rights,and she ar- defend and protect those roles,Willard proposed gued as well for equal rights. extending women the right to vote on prohibition The membership of the WCTU in the early issues as a means of further protecting women. At 1890s grew to an estimated 150,000 dues-paying the time of this proposal,the idea of granting members,with an additional 150,000in affiliated women the right to vote based on their natural or groups. The WCTU had reached out to women of political right to do so was not palatable to many all social classes and minority groups. The growing people,women and men alike. By introducing the influence of the WCTU was evident in the passage suffrage issue under the guise of home protection, of several state prohibition laws in the 1880s,as Willard was able to introduce the right-to-vote is- well as in the growing support for a federal consti- sue within the WCTU with less opposition than if tutional prohibition of liquor. she had sought solely to address women’s suffrage. Although the number of women involved in the As president,Willard ran the WCTU as a ‘‘well- WCTU would continue to grow to approximately oiled reform machine.’’ Emphasizing organization 1.5 million in the early twentieth century,as the at the local level,Willard was able to establish the nineteenth century drew to a close,the WCTU be- mass base necessary for effective action. By 1880 gan losing its power and importance. Most notably, the WCTU easily outstripped other women’s orga- Willard became less visible in the years preceding nizations in both size and importance. Bordin her death. In her absence,conflicts arose among (1981) estimates that there were 1,200 local unions other leaders of the movement as to the organiza- with 27,000 WCTU members by the time Willard tion’s proper direction. In addition,as older leaders became president. died or withdrew from active participation,fewer Under the leadership of Willard,the WCTU con- young women joined the WCTU to replace them. tinued many of the programs that were adopted 1898–Present. As other organizations en- while Wittenmeyer was president. A number of dorsing women’s rights and/or prohibition were states passed compulsory temperance-education developed,membership in the WCTU slowly laws,in large part due to the influence of the dwindled. Following Willard’s death in 1898,the WCTU. In addition,the omnipresent push for ab- WCTU returned to a single-issue approach,focus- stinence from alcoholic beverages continued to typ- ing solely on prohibition. Although the ultimate ify the movement’s goals—as is evidenced by the goal of prohibition would eventually be achieved,it brief alliance forged between the WCTU and the was not until the growth of the Anti-Saloon League Prohibition party. The WCTU of the 1880s,how- (established 1896) that national prohibition would ever,also departed from its roots on a variety of be realized. The Eighteenth Amendment to the U.S. issues. It evolved from a temperance praying soci- Constitution was proposed and sent to the states ety to an activist organization. Whereas Wit- December 18,1917,and was ratified by three tenmeyer sought for change through moral suasion, quarters of the states by January 16,1919; it be- Willard saw the advantages of political solutions to came effective January 16,1920,establishing that both the problems caused by intemperance as well the manufacture,sale,or transportation of intoxi- as the problems facing women. Willard supported cating liquors,for beverage purposes,was prohib- federal constitutional prohibition as the most effec- ited. During the 1920s,it was clear that enforce- tive way to deal with alcohol abuse,and she en- ment of the alcohol-beverage industry was almost dorsed the temperance ballot for women as the impossible and that Americans would not give up surest way to achieve prohibition. drinking easily. The Repeal of Prohibition began as By the mid-1880s,the WCTU had expanded to a movement that culminated in the Twenty-first every U.S. state and territory,and its platform had Amendment to the U.S. Constitution; it was pro- undergone similar expansion. Willard adopted the posed and sent to the states February 20,1933,and slogan ‘‘Do Everything’’ to describe the focus of the was ratified December 5,1933. WCTU under her guidance; initially,she had Small groups of WCTU members can still be coined this phrase to depict the lengths to which she found in,for the most part,rural areas of the WORLD HEALTH ORGANIZATION EXPERT COMMITTEE ON DRUG DEPENDENCE 1363

United States. The organization is based in Evans- metabolized to formaldehyde and formic acid by ton,Illinois,and listed about 100,000members in the same liver enzymes that break down ethanol 1990. (these are alcohol dehydrogenase and aldehyde dehydrogenase). The formaldehyde and formic acid (SEE ALSO: Alcohol; Disease Concept of Alcoholism are toxic metabolites responsible for the symptoms and Drug Abuse; Treatment, History of ) of methanol poisoning; these appear several hours or days after methanol ingestion. Blurred vision, BIBLIOGRAPHY leading to permanent bilateral blindness,is characteristic of methanol poisoning. The accumulation of AARON,P.,& M USTO,D. (1981). Temperance and prohi- formic acid results in severe metabolic acidosis, bition in America: A historical overview. In M. H. which can rapidly precipitate coma and death. Moore & D. R. Gerstein (Eds.), Alcohol and public Other symptoms of methanol toxicity include dizzi- policy. Washington,DC: National Academy Press. ness,headaches,cold clammy extremities,abdomi- BLOCKER,J. S. (1985). ‘‘Give to the winds thy fears’’: The nal pain,vomiting,and severe back pain. women’s temperance crusade, 1873–1874. Westport, The treatment for methanol poisoning is sodium CT: Greenwood Press. bicarbonate,given to reverse the acidosis. In more BORDIN,R. (1986). Frances Willard: A biography. serious cases,dialysis may be required; in addition, Chapel Hill,NC: University of North Carolina Press. ethanol is given intravenously because it competi- BORDIN,R. (1981). Woman and temperance: The quest tively binds to alcohol dehydrogenase,thereby for power and liberty, 1873–1900. Philadelphia: slowing the production of toxic metabolites and al- Temple University Press. lowing unchanged methanol to be excreted in the ESTEP,B. (1992). Losing its bite. Lexington Herald- urine. Leader,January 19,1,11. LENDER,M. E.,& M ARTIN,J. K. (1982). Drinking in BIBLIOGRAPHY America: A history. New York: Free Press. LEVINE,H. G. (1984). The alcohol problem in America: KLAASSEN,C. D. (1996). Nonmetallic environmental From temperance to alcoholism. British Journal of toxicants: Air pollutants, solvents and vapours, and Addiction, 79,109–119. pesticides,1673-1696,In: The pharmacological basis MENDELSON,J. H.,& M ELLO,N. K. (1985). Alcohol: Use of therapeuticsHARDMAN,J.G.,L IMBIRD,L. E., and abuse in America. Boston: Little,Brown. MOLINOFF,P. B.,R UDDON,R. W.,G ILMAN,A. G. The pharmacological basis of therapeutics,9th ed. New GARY BENNETT York: McGraw-Hill. MYROSLAVA ROMACH KAREN PARKER WOOD ALCOHOL (METHANOL) Meth- anol (methyl alcohol,CH 3OH) is the simplest of the alcohols. It is the natural by-product of wood distillation—an older method of producing drinking WORKPLACE, DRUGS IN THE See ALCOHOL (ethanol). Chemically synthesized meth- Employee Assistance Programs; Industry and anol is a common industrial solvent found in paint Workplace,Drug Use in remover,cleansing agents,and antifreeze. It is used to denature the ethanol found in some of these solutions and thereby render them unfit for drink- WORLD HEALTH ORGANIZATION EX- ing. PERT COMMITTEE ON DRUG DEPEN- Methanol ingestion is usually accidental,but DENCE The World Health Organization (WHO) some alcoholics resort to the desperate measure of originated from a proposal at the first United consuming methanol when they cannot obtain the Nations (U.N.) conference held in San Francisco in beverage ethanol. Persons working in poorly venti- 1945 that ‘‘a specialized agency be created to deal lated areas can suffer ill effects from inhaling meth- with all matters related to health.’’ This proposal anol-containing products,and ingestion of metha- resulted in a draft WHO constitution signed by nol is considered a medical emergency. Methanol is sixty-one governments at an international health 1364 WORLD HEALTH ORGANIZATION EXPERT COMMITTEE ON DRUG DEPENDENCE conference held in New York City in 1946. The The early meetings of the expert committee were constitution was subsequently ratified by the mainly devoted to the opioids—including the natu- twenty-six member states of the U.N. and came ral products,semisynthetics,and synthetics. Notifi- into force on April 7,1948. The enormous pro- cations on specific compounds by individual posed scope of WHO led to the early concept of nations were responded to and recommendations as ‘‘Expert Committees,’’ and they have become an to international control were communicated to the essential part of the machinery of the organization. secretary-general of the U.N. The beginnings of Their function is to give technical advice to WHO. often recurring discussions were initiated concern- Members of these committees are ‘‘appointed by ing definitions,methods for evaluating dependence the Director-General,in accordance with regula- liability in animals and humans,the need for accu- tions established by the Executive Board.’’ The rate epidemiological data concerning the extent of members are chosen for their ‘‘abilities and techni- abuse and public health problems associated with cal experience’’ with ‘‘due regard being paid to drugs in general and of specific compounds in par- adequate geographical distribution.’’ Reports of ticular. During this period,the expert committee expert committees can only be published with the had an important consultative role in the develop- authorization of the World Health Assembly or the ment of a new international drug-control treaty, WHO executive board. which resulted in an international conference held One of the first tasks of the U.N. and WHO was in New York City in January 1961. From this Con- to pick up the regulatory work on addiction-pro- ference emerged the SINGLE CONVENTION ON NAR- ducing drugs that had been initiated and carried COTIC DRUGS,1961. This convention was amended out by the League of Nations. Thus,the Expert in 1972,again with strong input from the expert Committee on Habit-Forming Drugs was estab- committee,and remains the current instrument for lished in 1948 to provide expert technical advice to the international control of the opioids,cocaine, the U.N. Permanent Central Opium Board and and cannabis (marijuana). Drug Supervisory Body and the Division of Nar- The committee’s concern for the potential abuse cotic Drugs. The first meeting of the expert com- of the newly emerging ataractics (tranquilizing mittee was held January 24–29,1949,at the Palais drugs) began in the mid-1950s and was soon joined des Nations in Geneva,Switzerland,where it con- in the 1960s by discussions of the problems created tinued to meet until the WHO building was opened by amphetamines,amphetamine-like drugs,and in 1961. The expert committee,in its report on the hallucinogens. The difficulties associated with con- second session,felt that the expression ‘‘habit trolling these new heterogeneous groups of drugs forming’’ was no longer appropriate and recom- under the Single Convention of 1961 became ap- mended that the designation of the committee be parent and,at its seventeenth meeting in 1969,the changed to Expert Committee on Drugs Liable to committee began discussions of a draft Protocol on Produce Addiction. This change was adopted by Psychotropic Substances,developed by the U.N. the WHO executive board at its fifth session and Commission on Narcotic Drugs,which formalized a remained until 1964,when it was altered to Expert classification of psychotropic drugs developed by Committee on Dependence Producing Drugs and the expert committee at its sixteenth meeting in finally in 1968 to its present designation,Expert 1968. The increasingly serious international pub- Committee on Drug Dependence. lic-health problems created by these drugs led the In its early years,the expert committee reported United Nations to hold a conference for the Adop- directly to the director-general of WHO through its tion of a Protocol on Psychotropic Substances held own secretary. In 1965,it became part of the Divi- in Vienna in February 1971; this resulted in the sion of Pharmacology and Toxicology. During Convention on Psychotropic Substances,1971, much of the period from its inception to 1972,the which the United Nations finally ratified in 1976. Seretariat was in the hands of Dr. Hans Halbach. In One important feature of this convention is that it 1977,the expert committee became part of the mandates a WHO assessment of a substance prior Division of Mental Health,under the direction of to control and states that WHO’s ‘‘assessments Dr. Inayat Khan,where it remained until 1990 shall be determinative as to medical and scientific when a new Programme on Substance Abuse was matters.’’ This mandate added great responsibility created. to the functional role of the expert committee. WORLD HEALTH ORGANIZATION EXPERT COMMITTEE ON DRUG DEPENDENCE 1365

Only two meetings of the expert committee were Initially,to handle WHO’s necessary functions held between the adoption of the Convention on under the conventions,it was decided to use ad-hoc Psychotropic Substances in 1971 and its ratifica- advisory groups rather than to call formal meetings tion in 1976. The nineteenth meeting in 1972 was of the expert committee. The first of these was held mainly devoted to a review of the current status of in 1978. In 1979,specific compounds were consid- the epidemiological study of drug dependence. This ered under both conventions and the recommenda- meeting was also the last attended by Dr. Nathan B. tion was made that,in the future,compounds pro- Eddy,before his death in 1973. Dr. Eddy,a giant posed for control under the psychotropic in the study of drug abuse and dependency,was at convention be considered by class. In 1980,nine all the first nineteen meetings and served as chair- anorectic substances (things that cause loss of ap- man or rapporteur for most of them. The twentieth petite) were reviewed and recommendations as to meeting of the committee was essentially devoted to control were forwarded. Discussions concerning the topic of prevention and resulted in a thorough KHAT and its active principals,cathine and review of the literature and a series of conclusions cathinone,were begun and research was initiated and recommendations,which were of considerable by a widespread group of laboratories. In 1981,the influence in the future development of the field. mixed opioid AGONIST-ANTAGONIST drugs were re- The twenty-first meeting of the committee was viewed,and in 1981 and 1982 the B ENZODIAZE- held in 1977. It was entirely concerned with con- PINES as a class were reviewed and recommenda- sideration of the Convention on Psychotropic Sub- tions for control were sent to the U.N. Also during stances,and how WHO would handle its obliga- this period a more formal method for review tions under the treaty. This included consideration emerged from discussions with the U.N. Commis- of appropriate pharmacological studies in animals sion on Narcotic Drugs and the WHO Executive and humans,assessment of public-health and so- Board. Detailed critical reviews of substances to be cial problems,assessment of therapeutic useful- considered for control were developed and the Pro- ness,the problem of chemically generic extensions gramme Planning Working Group was formed to to the list of scheduled substances,and the deci- review these and suggest future classes of com- sion-making process. The meeting resulted in a pounds for review by the expert committee. Two number of recommendations that were mainly con- additional ad hoc advisory committee meetings cerned with international cooperation in the devel- were held in 1983 and 1984 to consider a variety of opment and collection of the relevant data needed individual compounds and exempt preparations. to make rational decisions on controlling sub- The twenty-second meeting of the expert com- stances under the convention. mittee was held in Geneva in April 1985. The The expert committee did not meet formally committee adopted the new procedures for review again until 1985. In the interim,however,a num- of substances recently approved by the WHO Exec- ber of WHO ad-hoc committees met to consider utive Board. These guidelines mandated a proce- various aspects of the implementation of the treaty. dural sequence and schedule for the review. WHO In 1980,an extensive review of the Assessment of was to obtain detailed information on each sub- Public Health and Social Problems Associated with stance from a wide variety of sources including the Use of Psychotropic Drugs was carried out. To individual experts,research groups (e.g.,WHO assist WHO,the U.S. National Institute on Drug Collaborating Centers),the pharmaceutical indus- Abuse,in collaboration with the Committee on try,and relevant publications. It should be noted Problems of Drug Dependence,published a mono- that this was the first time that the pharmaceutical graph on ‘‘Testing Drugs for Physical Dependence industry was included in deliberations concerning Potential and Abuse Liability,’’ which updated a regulatory control of their products. The twenty- similar WHO report published a decade earlier. A second meeting was held,primarily,to consider particularly difficult section of the psychotropic twenty-eight phenethylamines for control under convention concerns exempt preparations. This in- the Psychotropic Convention. A large number of volves thousands of pharmaceutical products and groups and individuals was involved in preparing how to handle them,and it has still not been com- the critical review of these substances. Many of the pletely resolved despite three meetings of WHO substances considered were recommended for con- advisory groups in 1977,1982,and 1984. trol under various schedules of the Psychotropic 1366 WORLD HEALTH ORGANIZATION EXPERT COMMITTEE ON DRUG DEPENDENCE

Convention. Some were not considered to need con- opioid agonist-antagonist analgesics and recom- trol,and no recommendation was made on these. mended that BUPRENORPHINE and pentazocine be Among the recommendations emerging from this controlled under Schedule III of the Psychotropic meeting were requests for more and better data, Convention. This was a significant departure and particularly epidemiological,and more consider- was the first time that compounds with some opi- ation of structure-activity relationships,isomeric oid-like properties were considered for control un- state,and drug metabolism. der this convention rather than the Single Conven- The twenty-third meeting in 1986 was nearly tion,1961. A number of other compounds were entirely devoted to the review of thirty-one considered for control,the most interesting being BARBITURATES. A number of new factors were con- propylhexadrene. This substance was the first to be sidered in the deliberations on this group of drugs. considered for decontrol under the Psychotropic These included therapeutic indication (e.g.,ul- Convention. The committee recommended that ad- trashort-acting intravenous anesthetics,intermedi- ditional epidemiological data be collected and the ate-acting sedative-hypnotics,and anticonvul- substance reviewed again in two years. This was sants),therapeutic usefulness,and demonstrable done in 1990,and a recommendation to remove international public-health and social problems. propylhexadrene from control was forwarded to the Particular concern was expressed concerning U.N. secretary-general. PHENOBARBITAL,an inexpensive,effective an- The twenty-sixth meeting of the committee in tiepileptic widely used in developing countries, 1989 considered four additional uncontrolled ben- since it was felt by some that international control zodiazepines and recommended control for only might lead to the use of more expensive and less one. The remainder were held over for the twenty- safe medications. The committee also noted a lack seventh meeting,in which the 33 benzodiazepines of data on many compounds concerning depen- already under control were to be reviewed. This dence potential from either animals or controlled meeting also recommended the control of a number clinical studies and recommended that this be sys- of ‘‘DESIGNER DRUGS,’’ including analogs of tematically collected by WHO prior to consider- fentanyl,tenamfetamine (MDA),and aminorex. ation for control. Also considered was the notification from the gov- The twenty-fourth meeting in 1987 discussed ernment of the United States to transfer delta-9- the control of seven nonbarbiturate sedative hyp- tetrahydrocannabinol,the active principle of M ARI- notics. None of these were recommended for con- JUANA,from Schedule I to Schedule II of the Con- trol. The committee also considered the marked vention on Psychotropic Substances. The commit- increase in the illicit traffic in SECOBARBITAL and tee so recommended,with the exception of two recommended that it be moved from Schedule III to members who felt the decision should be deferred Schedule II of the Psychotropic Convention. Fi- for additional data concerning therapeutic useful- nally,the committee recommended control of a ness. number of fentanyl and MEPERIDINE analogs under The twenty-seventh and last meeting to date of the Single Convention. the expert committee was held in 1990 and was The twenty-fifth meeting in 1988 considered the essentially devoted to the scheduling of the benzo- control of an additional four nonbarbiturate seda- diazepines as a class. Of particular interest was the tive-hypnotics including METHAQUALONE,which conclusion that differential scheduling of the ben- had been suggested for control in Schedule I of the zodiazepines was possible. Thus,the committee Psychotropic Convention at the twenty-fourth ex- recommended that of the thirty-three substances pert committee meeting. Of these compounds,only currently under control,nineteen were appropri- methaqualone was recommended for control. The ately controlled under Schedule IV. Thirteen of the committee did not recommend rescheduling to substances had moderate to high therapeutic use- Schecule I but urged the secretary-general of WHO fulness and few or no reports of abuse or illicit that ‘‘every effort should be made to urge all coun- activity,and the committee declared that WHO tries whether or not they are signatories to the should ‘‘monitor these compounds to amass enough Convention on Psychotropic Substances,1971,to data to determine whether or not they should be stop producing methaqualone and to ban its import placed under critical review to consider or export.’’ The expert committee also revisited the descheduling.’’ Two compounds,diazepam and XTC 1367

ﬂunitrazepam,‘‘showed a continuing higher inci- BIBLIOGRAPHY dence of abuse and association with illicit activity.’’ It was recommended that WHO keep these com- ENCYCLOPAEDIA BRITANNICA,vol 13,232–233. pounds under surveillance ‘‘to determine whether HANDBOOK OF RESOLUTIONS AND DECISIONS OF THE WORLD or not they merit being placed under critical review HEALTH ORGANIZATION ASSEMBLY AND THE EXECUTIVE to consider appropriate scheduling.’’ BOARD,vols. I and II. Geneva: World Health Organiza- As a result of structural changes within WHO tion,1985. and the creation of the new Programme on Sub- W.H.O. WHAT IT IS, WHAT IT DOES. Geneva: World Health stance Abuse,it is clear that in the future the expert Organization,1988. committee will change its focus from reviewing LOUIS HARRIS substances for control under the international conventions to a broader consideration of the issues of prevention and reduction of demand. XTC See Slang and Jargon (SEE ALSO: Abuse Liability of Drugs: Testing in Humans) Y

YIPPIES When large numbers of individuals During that time, a team of scientists surveyed with shared values engage in certain patterns of the drug-use activity of 432 Yippies (Hughes et al. drug use, the political consequences can be serious. 1969). These showed a strong preference for hallu- The Yippies of the late 1960s and early 1970s pro- cinogenic substances. Weekly MARIJUANA use was vide such an example. reported by 79 percent, HASHISH by 40 percent, Rather than quietly retreating from society as LYSERGIC ACID DIETHYLAMIDE (LSD) by 29 per- part of the baby-boom’s countercultural (hippie) cent, MESCALINE by 10 percent, PSILOCYBIN by 5 revolution, the Yippies shocked those with conven- percent, and PEYOTE by 3 percent. Weekly use of tional values in the United States through spectacu- nonhallucinogens was low—ALCOHOL 34 percent, lar media events. Thousands of young Americans COCAINE 4 percent, and HEROIN 3 percent. shared the antimaterialistic values of Yippie leaders It may be too simplistic to attribute the 1968 Abbie Hoffman and Jerry Rubin. In 1967, Hoffman political events to marijuana and LSD. Yet we do dumped dollar bills from the visitors’ gallery onto know that certain chemicals help free users from the floor of the New York Stock Exchange. In 1968, conventional values and ways of perceiving reality. another protest event was staged—the Chicago Researchers need to further examine this issue in Yippie Convention—timed to coincide with the future outbreaks of antiestablishment protest. Chicago Democratic Presidential Convention and considered an opportunity to protest the VIETNAM War. (SEE ALSO: Epidemics of Drug Abuse; Hallucino- Yippies challenged the establishment with a Fes- gens) tival of Life and invited drug-using hippies to attend; it included LSD seminars, rock shows, light BIBLIOGRAPHY shows, films, marches, love-ins, put-ons, guerrilla theater, and bizarre stunts—such as nominating a FIEGELSON, N. (1970). The underground revolution: pig named Pigasus for president. The protest esca- Hippies, Yippies, and others. New York: Funk & lated into a confrontation with Chicago authorities; Wagnalls. the mayor called out the police; and, in a rioting HOFFMAN, A. (1989). On to Chicago. In Daniel Simon atmosphere, Yippies were beaten and imprisoned; (Ed.), The best of Abbie Hoffman. New York: Four the presidential convention was disrupted; Yippie Walls Eight Windows. leaders were tried in a case that became known as HUGHES, P., ZAKS, M., JAFFE, J., & BALLOU-DOLKART,M. the Chicago Seven; and the Democrats lost the (1969). The Chicago Yippie convention of 1968— 1968 election. drug use patterns. Scientific Proceedings of the One

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Hundred Twenty-Second Annual Meeting. Washing- YOUTH AND SUBSTANCE ABUSE See ton, DC: American Psychiatric Association. Adolescents and Drugs; Gangs and Drugs; Preven- ZAKS, M., HUGHES, P., JAFFE, J., & BALLOU-DOLKART,M. tion Programs; Treatment (1969). Chicago Yippie convention, 1968: Socio-cultural drug use and psychological patterns. American Journal of Orthopsychiatry, 39(2):188–190. YUPPIES See Slang and Jargon PATRICK H. HUGHES Z

ZERO TOLERANCE The phrase has come criminal act, with legal sanction as the conse- to be associated with government and private em- quence. ployer policies that mandate predetermined conse- Zero tolerance is a ‘‘user-focused’’ strategy of quences or punishments for specific offenses. How- drug control, according to which law-enforcement ever, the phrase first became associated with U.S. agents target users of illicit drugs as opposed to drug interdiction during the 1980s and 1990s. dealers or transporters. The rationale for this ap- Most public schools now have zero tolerance poli- proach is that the users of illicit substances create cies for firearms, weapons other than firearms, al- the demand for drugs and constitute the root cause cohol, drugs, and tobacco. Zero tolerance policies of the drug problem. If, therefore, demand for generally are rigid and can produce results that drugs can be curbed by exacting harsh penalties on users, the supply of drugs into the country will appear out of proportion to the improper behavior. slow. Nevertheless, the courts have endorsed drug-test- The zero-tolerance policy was initiated by the ing programs that allow employers to enforce zero U.S. CUSTOMS SERVICE, in conjunction with the tolerance policies. U.S. Attorney’s office in San Diego, California, as part of an effort to stop drug trafficking across the ZERO TOLERANCE AND U.S. DRUG U.S.-Mexican border. Individuals in possession of CONTROL POLICY illicit drugs were arrested and charged with both a misdemeanor and a felony offense. Customs Ser- Zero tolerance was a federal drug policy initi- vice officials believed the policy to be successful at ated during the War on Drugs campaign of the reducing the flow of drugs across the border and Reagan and Bush administrations (1981–1993). recommended that it be implemented nationwide. Under this policy, which was designed to prohibit Subsequently, the National Drug Policy Board, in the transfer of illicit drugs across U.S. borders, no conjunction with the White House Conference on a possession, import, or exportation of illicit drugs Drug-Free America had all federal drug-enforce- was tolerable, and possession of any measurable ment agencies implement zero tolerance in 1988, at amount of illicit drugs was subject to all available all U.S. points of entry (United States Congress, civil and criminal sanctions. Zero tolerance was an 1988). example of a criminal justice approach to drug The policy did not involve enacting new laws or control. Under such an approach, the control of regulations; it only entailed instituting strict inter- drugs rests within the domain of the criminal jus- pretation and enforcement of existing laws. In tice system, and the use of drugs is regarded as a practice, it meant that any type of vehicle—

1371 1372 ZERO TOLERANCE including bicycles, transfer trucks, and yachts— ees challenged these policies in the courts. How- would be confiscated and the passengers arrested ever, the U.S. Supreme Court, in New York City upon the discovery of any measurable amount of Transit Authority v. Beazer, 440 U.S. 568, 99 S.Ct. illicit drugs. The U.S. Coast Guard and the U.S. 1355, 59 L.Ed.2d 587 (1979), ruled that a city Customs Service began to crack down on all cases agency’s blanket exclusion of persons who regu- of drug possession on the water and at all borders. larly use narcotic drugs did not violate the Equal If, during the course of their regular patrols and Protection Clause of the Fourteenth Amendment. inspections, Coast Guard personnel boarded a ves- This zero tolerance decision subsequently has been sel and found one marijuana cigarette, or even the extended to various employment situations. By remnants of a marijuana cigarette, they arrested 2000, many employers routinely required a drug the individual and seized the boat. Before this pol- test as part of the employee hiring process. Appli- icy was instituted, the Coast Guard had either cants who failed the test usually are not hired be- looked the other way or issued fines when ‘‘per- cause employers use a zero tolerance drug policy. sonal-use’’ quantities of illicit substances were dis- Zero tolerance policies have become a standard covered (United States Congress, 1988). part of U.S. public schools. With the rash of school Zero tolerance was criticized because federal shootings in the 1990s, zero tolerance weapons pol- agencies expended substantial resources to identify icies have dominated the news, yet zero tolerance individual drug users instead of concentrating their drug polices are also part of school rules. Zero resources on halting the influx of major quantities tolerance has widespread public support, as it man- of drugs into the country for street sale. The policy of seizing boats upon the discovery of trace dates high standards and signifies a ‘‘get tough’’ amounts of drugs was also controversial. Some be- attitude toward drugs and school violence. Never- lieved the policy to be an unfair and unusually theless, there are many critics of zero tolerance harsh punishment; seizing a commercial boat that polices. Critics analogize zero tolerance to manda- was the sole source of income for an individual or tory minimum sentencing in the criminal justice family was denounced as being too severe a penalty system. Under both schemes there are no excep- for possession of ‘‘one marijuana cigarette.’’ There tions made for individual circumstances; this re- were some highly publicized cases of commercial sults in punishments that appear excessive, such as fishing boats being seized on scant evidence that a student suspension for bringing aspirin to school the boat owner was responsible for the illicit drugs without permission. found. (SEE ALSO: Drug Interdiction; Operation Intercept; ZERO TOLERANCE AS A U.S. Government: The Organization of U.S. Drug GENERAL POLICY Policy) The term zero tolerance has a broader application than the Reagan-Bush drug interdiction ap- BIBLIOGRAPHY proach. Zero tolerance describes a perspective on UNITED STATES CONGRESS.HOUSE COMMITTEE ON MER- drug use according to which it is maintained that CHANT MARINE AND FISHERIES.SUBCOMMITTEE ON the use of any amount of illicit drugs is harmful to COAST GUARD AND NAVIGATION. (1988). ‘‘Zero Toler- the individual and society and that the goal of drug ance’’ drug policy and confiscation of property: Hear- policy should be to prohibit any and all illicit drug ing before the Subcommittee on Coast Guard and use. According to the contrasting viewpoint, the Navigation of the Committee on Merchant Marine and simple use of drugs is distinguishable from problem Fisheries (House of Representatives, 100th Congress, drug use and although absence of all drug use is 2nd session). Washington, DC: U.S. Government desirable, the resources of government would be used more efficiently if they targeted individuals Printing Office. who demonstrated problem use or if they addressed CURWIN,R.L.&MENDLER, A. N. (1999). Zero tolerance problems related to or caused by illicit drug use. for zero tolerance. Phi Delta Kappan 81, 119. Drug testing in the workplace typically uses a AMY WINDHAM zero tolerance approach. In the late 1970s, employ- REVISED BY FREDERICK K. GRITTNER ESA&AB-barcode/v3.qx4 10/27/00 4:03 PM Page 1

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