CPSS420W5

Chapter 5 Screening, Diagnosis, Assessment, and Referral

This chapter presents a systems or biopsychosocial approach to determining whether an individual has a chemical abuse or dependency problem. The first steps in this approach are screening and diagnosis. The chapter also considers the extension of this process, called assessment, to examine the client’s needs further. A thorough assessment is generally needed to develop a treatment plan and to make referrals to appropriate resources.

Some individuals with alcohol and drug problems experience medical emergencies (intentional overdoses, accidental alcohol or drug poisoning, pancreatitis, delirium tremens, seizures, etc.) that require immediate attention. Social workers, psychologists, and other human service professionals should know what these emergencies are, but these problems can be diagnosed and treated only by qualified medical personnel. This chapter focuses primarily on the work of helping professionals once such medical crises have been resolved or when a client is seen by a helping professional before these medical complications arise.

We begin by discussing screening, which may be defined as the use of rapid assessment instruments and other tools to determine the likelihood that an individual has a chemical abuse or chemical dependency problem. In practice, much screening is informal and is not done with structured or standardized instruments. For example, after reviewing a parolee’s “rap sheet” containing repeated alcohol- or drug-related arrests, a parole officer may feel that is all the screening necessary for referring the client to a chemical dependency treatment program or insisting on participation in a mutual-help group as a condition of parole.

Diagnosis is the confirmation of a chemical abuse or dependency problem based on established clinical criteria. The diagnostic process generally involves an interview with the patient or client and often includes information from other sources such as a medical examination, including laboratory tests, and previous medical, psychological or psychiatric, criminal, school, and other records. Consultation with other professionals might also be used as is information from collaterals (e.g., family) who know the patient or client well.

The term assessment is sometimes used synonymously with the term diagnosis, but we use it to mean an in-depth consideration of the client’s chemical abuse or dependency problems as they have affected his or her psychological well-being, social circumstances (including interpersonal relationships), financial status, employment or education, health, and so forth. This process also includes consideration of the individual’s strengths and resources that may be assets in treatment and recovery. Going beyond a confirmatory diagnosis, this type of multidimensional or biopsychosocial assessment provides the basis for treatment planning.

The cornerstones of screening, diagnosis, and assessment are knowledge of substance use disorders and good interviewing skills, including the ability to establish some level of rapport with clients in a relatively brief period. Denial is a pervasive issue in work with clients who have alcohol and drug problems. Helping professionals must frequently work with clients and their significant others to reduce defensiveness and resistance; thus, this chapter addresses these topics. The assurance of confidentiality in treatment and research settings can increase the validity of clients’ reports of their alcohol and drug problem ( National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1990 ), but the extent to which confidentiality can be guaranteed varies and should be represented fairly to the client. Confidentiality, as well as other aspects of ethical or professional conduct, also warrants attention in this chapter.

In addition to chemical dependency treatment, clients often need the services of other agencies. The final section of this chapter discusses the process of referring clients to other services, including mutual-help groups.

Screening

Screening for alcohol and drug problems is done in many types of settings in addition to chemical dependency programs, such as in health care facilities, mental health programs, and correctional facilities.

Although much work is being done, there is currently no biological testing procedure that most human service professionals can easily use to identify people with substance use disorders or those who have the potential to develop these problems (see  Allen, Sillanaukee, Strid, & Litten, 2003 ;  Substance Abuse and Mental Health Services Administration, 2006 ). Instead, human service professionals generally inquire about family history of alcohol and drug problems, the quantity and frequency of the individual’s own drinking or drug use, and especially the individual’s alcohol-and drug-related problems. To do this, they often use one of a number of the paper-and-pencil or verbally administered tests specifically designed to screen for chemical abuse or dependence problems. Some of the many screening instruments available are the CAGE (defined shortly), the Michigan Alcoholism Screening Test (MAST), the Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), the Problem Oriented Screening Instrument for Teenagers (POSIT), and the Substance Abuse Subtle Screening Inventory (SASSI). Before these instruments are administered, there should be some interaction between the client and the treatment professional in order to explain the purpose of the screening, to put the client at ease, to encourage honest responses, and to answer questions the client might have about the procedure.

CAGE

Screening devices as short as one or two items have been tested for use in busy medical practices ( Brown, Leonard, Saunders, & Papasouliotis, 2001 ;  Smith, Schmidt, Allensworth-Davies, & Saitz, 2009 ), but the CAGE, developed by John Ewing and Beatrice Rouse, is the briefest of the most widely used screening instruments (see  Ewing, 1984 ;  Mayfield, McLeod, & Hall, 1974 ). The CAGE consists of four questions asked directly to the patient:

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

The letters in bold type in each question makeup the acronym that serves as the instrument’s name; the letters also serve as a mnemonic device so that the instrument is easily committed to memory. A positive response to one or more of the questions indicates the need to explore problems the patient or client may be experiencing with the use of alcohol. Two or more positive responses generally indicate a positive test ( Buchsbaum, 1995 ;  Liskow, Campbell, Nickel, & Powell, 1995 ). This tool is easily used in many types of clinical settings. The CAGE is generally reported to be effective in identifying adults with alcohol problems ( Bush, Shaw, Cleary, Delbanco, & Aronson, 1987 ;  Liskow et al., 1995 ). Since the CAGE inquires only about alcohol, the CAGE Adapted to Include Drugs (CAGE-AID) may be used with instructions to the patient or client that “when thinking about drug use, include illegal drug use and the use of prescription drugs other than as prescribed” ( Brown, Leonard, Saunders, & Papasouliotis, 1998 , p. 102; also see  Lanier & Ko, 2008 ). These instructions are useful in screening individuals who are taking pain medication and those who have been prescribed medications for psychiatric disorders and are using them inappropriately.

Michigan Alcoholism Screening Test (MAST)

Another widely used screening instrument for alcohol problems is the Michigan Alcoholism Screening Test (MAST) ( Selzer, 1971 ). It has been shown to have good validity and reliability ( Lettieri, Nelson, & Sayers, 1985 ;  Skinner, 1979 ). The original MAST contains 25 items and is usually self-administered (i.e., the client is asked to read and complete it). As with most screening instruments, clarifying clients’ responses can be helpful. For example, question 3 on the MAST is “Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?” Drinkers married to teetotalers may respond positively to this question even if their drinking is not problematic, or an individual with ties to a religious group that prohibits drinking may respond positively to question 5 (“Do you ever feel guilty about your drinking?”) regardless of how much he or she drinks.

Shorter versions of the MAST are also available (see  Connors & Volk, 2003 ). One, called the Short MAST or the SMAST, contains 13 questions ( Selzer, Vinokur, & van Rooijen, 1975 ). Another is the Brief MAST (B-MAST), which contains ten questions ( Pokorny, Miller, & Kaplan, 1972 ). The shorter versions are often used with slower readers. These instruments may also be tape-recorded or read to the client or patient by the person administering the test. The MAST has been used as a screening tool in many settings, such as in programs for those convicted of driving under the influence (DUI).

Alcohol Use Disorders Identification Test (AUDIT)

The World Health Organization (WHO) developed the Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for use by primary health care providers ( Babor, Higgins-Biddle, Saunders, & Monteiro, 2001 ). Social service providers can also use it. As  Figure 5.1  shows, the AUDIT contains ten items. Items 1 through 3 concern hazardous drinking (frequency and quantity), items 4 through 6 concern alcohol dependence, and items 7 through 10 refer to harmful alcohol use (alcohol-related problems). The AUDIT can be administered as a self-report questionnaire or as an interview. Clinical screening procedures (a physical exam and laboratory tests), which can only be administered by qualified health care providers, are also recommended, especially when an individual may not be candid about alcohol use or cannot provide answers to questions or when additional information is needed. The clinical indicators include blood vessels appearing in the face, hand and tongue tremor, changes in mucous membranes and mouth, and elevated liver enzymes observed through tests such as the serum gamma-glutamyl transferase (GGT). The AUDIT is available in a number of languages. Since drinking preferences and customs vary among cultures, these factors must be taken into account when administering the AUDIT. For example, the number of drinks specified in items 2 and 3 may require adjusting, since serving size and alcohol strength vary among countries. As  Figure 5.1  also shows, the patient’s score indicates the type of intervention needed.

FIGURE 5.1 The Alcohol Use Disorders Identification Test (AUDIT): Interview Version

Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks.” Place the correct answer number in the box at the right.

1. How often do you have a drink containing alcohol?

1. (0) Never (Skip to Questions 9-10)

2. (1) Monthly or less

3. (2) 2 to 4 times a month

4. (3) 2 to 3 times a week

5. (4) 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1. (0) 1 or 2

2. (1) 3 or 4

3. (2) 5 or 6

4. (3) 7, 8, or 9

5. (4) 10 or more

3. How often do you have six or more drinks on one occasion?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily

Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0

4. How often during the last year have you found that you were not able to stop drinking once you had started?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily or almost daily

5. How often during the last year have you failed to do what was normally expected from you because of drinking?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

1. (0) Never

2. (1) Less than monthly

3. (2) Monthly

4. (3) Weekly

5. (4) Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?

1. (0) No

2. (2) Yes, but not in the last year

3. (4) Yes, during the last year

10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?

1. (0) No

2. (2) Yes, but not in the last year

3. (4) Yes, during the last year

Record total of specific items here 

Risk Level	Intervention	AUDIT Score *
*The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence. It may also be instructive to review the patient’s responses to individual questions dealing with dependence symptoms (see Questions 4, 5, and 6) and alcohol-related problems (see Questions 9 and 10). Provide the next highest level of interventation to patients who score 2 or more on Questions 4, 5, and 6, or 4 on Questions 9 or 10.
Zone I	Alcohol Education	0–7
Zone II	Simple Advice	8–15
Zone III	Simple Advice plus Brief Counseling and Continued Monitoring	16–19
Zone IV	Referral to Specialist for Diagnostic Evaluation and Treatment	20–40

Source: T. F. Babor, J. C. Higgins, J. B. Saunders, & M. G. Monteiro, AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2nd ed. (Geneva, Switzerland: World Health Organization, 2001), Reprinted with permission of the World Health Organization.

Drug Abuse Screening Test (DAST)

Some instruments, such as the Drug Abuse Screening Test, are used to screen for drug problems other than alcohol ( Skinner, 1982 ; also see  Lanier & Ko, 2008 ). The DAST was patterned after the MAST. Like the CAGE, MAST, and ten-item AUDIT, the DAST relies on the client or patient’s responses to questions. The 10-, 20-, and 28-item versions of the DAST are reported to have good psychometric properties ( Yudko, Lozhkina, & Fouts, 2007 ). Figure 5.2 contains the 20-item version.

Problem Oriented Screening Instrument for Teenagers (POSIT)

An instrument often used with adolescents is the Problem Oriented Screening Instrument for Teenagers (POSIT) ( Winters, 1999 ,  2003 ; also see  Knight, Sherritt, Harris, Gates, & Chang, 2003 ). POSIT is a screening tool for substance use problems and social, behavioral, and learning problems. The 139-item POSIT is longer than other tools described thus far and takes 20 to 30 minutes to complete. It is self-administered, requiring a fifth-grade reading level, and is available in English and Spanish.

Substance Abuse Subtle Screening Inventory (SASSI)

The Substance Abuse Subtle Screening Inventory (SASSI) is another instrument the client completes ( Lazowski, Miller, Boye, & Miller 1998 ;  Miller & Lazowski, 1999 ,  2001 ,  2005 ). There is a version for adults and one for adolescents. The SASSI differs from many instruments available in the field because most of the true/false items on one side of the form do not inquire directly about alcohol or drug use. The reverse side of the SASSI form contains another set of questions (formerly called the Risk Prediction Scales) ( Morton,1978 ) that do inquire directly about alcohol and other drug abuse. The SASSI therefore contains both face-valid items and subtle items that are empirically derived. Administration of the subtle true/false items before the more obvious alcohol- and drug-related questions may help minimize client defensiveness. Since the denial or defensiveness common among many persons with chemical dependency problems may result in failure to provide accurate information on face-valid, self-report measures, there has been interest in less obtrusive measures of substance use disorders such as the SASSI.

FIGURE 5.2 Drug Abuse Screening Test (DAST-20)

The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is “Yes” or “No.” Then, circle the appropriate response beside the question. In the statements “drug abuse” refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions and (2) any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

These questions refer to the past 12 months. Circle your response.

1. Have you used drugs other than those required for medical reasons?	Yes	No
2. Have you abused prescription drugs?	Yes	No
3. Do you abuse more than one drug at a time?	Yes	No
4. Can you get through the week without using drugs?	Yes	No
5. Are you always able to stop using drugs when you want to?	Yes	No
6. Have you had “blackouts” or “flashbacks” as a result of drug use?	Yes	No
7. Do you ever feel bad or guilty about your drug use?	Yes	No
8. Does your spouse (or parents) ever complain about your involvement with drugs?	Yes	No
9. Has drug abuse created problems between you and your spouse or your parents?	Yes	No
10. Have you lost friends because of your use of drugs?	Yes	No
11. Have you neglected your family because of your use of drugs?	Yes	No
12. Have you been in trouble at work because of drug abuse?	Yes	No
13. Have you lost a job because of drug abuse?	Yes	No
14. Have you gotten into fights when under the influence of drugs?	Yes	No
15. Have you engaged in illegal activities in order to obtain drugs?	Yes	No
16. Have you been arrested for possession of illegal drugs?	Yes	No
17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?	Yes	No
18. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?	Yes	No
19. Have you gone to anyone for help for a drug problem?	Yes	No
20. Have you been involved in a treatment program specifically related to drug use?	Yes	No

Source: Drug Abuse Screening Test (DAST-20) is reprinted by permission of the Centre for Addiction and Mental Health, Toronto, ON, Canada. Copyright © 1982.

The SASSI includes a set of decision rules to determine if the respondent fits the profile of a chemically dependent individual. Additional guidelines can be helpful in identifying some substance abusers who are not dependent. Separate profiles are used to score results for men and women. In addition to its basic function as a substance abuse and dependence screening instrument, the SASSI may provide other useful information. Clinical experience indicates that elevations on specific scales that comprise the SASSI reflect such things as defensiveness, willingness to acknowledge problematic behavior, depressed affect, focus on others, and relative likelihood of legal problems. The SASSI can be administered as a paper-and-pencil test or on a computer.

MacAndrew Alcoholism Scale

Another device included under the category of screening tools is the MacAndrew Alcoholism Scale ( MacAndrew, 1965 ). It is a subscale of the well-known Minnesota Multiphasic Personality Inventory (MMPI), which psychologists often use to detect a wide range of mental disorders. The items are unobtrusive and have been used for more than four decades. Special training and approval are required to interpret the MMPI.

Utility of Screening Instruments

The screening instruments discussed thus far are generally reported to have good validity and reliability by their authors, and for the most part, other researchers have provided evidence of their utility. Other factors to recommend them are that most are easy to administer, and they generally take from about 1 to 20 minutes to complete (depending on the instrument). Except for the MMPI and the AUDIT’s clinical screening procedures, they can be administered and scored by most human service professionals who need relatively minimal special training in their use.

We have discussed just a few of the instruments that may be useful to human service professionals in screening for substance abuse and dependence.  Allen and Wilson (2003)  and several volumes in the Substance Abuse and Mental Health Services Administration’s Treatment Improvement Protocol Series provide additional discussion of screening devices and screening methods. In conducting screenings and assessments for alcohol and drug problems, treatment providers often use instruments to detect other problems the client may be experiencing, such as depression, suicidal ideation, or other psychiatric problems.

Can People with Alcohol and Drug Problems Be Believed?

In our section on screening, we mentioned the terms validity and reliability (see, for example,  Allen, 2003 ;  Connors & Volk, 2003 ). These are basic social science concepts. An instrument is reliable if it produces the same results with the same person at different times and under different circumstances. For example, if the MAST or the SASSI were administered to a client today during a visit to an outpatient clinic, one would expect the same or very similar results if it were administered to the client next week at his or her home. If an instrument does not consistently produce the same results, it is not very reliable.

Validity refers to whether an instrument measures what one wants it to measure. In this case, human service professionals want to be sure they are using an instrument that will detect alcohol or drug problems, not some other concept such as bipolar disorder or antisocial personality disorder. Professionals may also be interested in these problems, but they clearly want to know which instruments should be used to screen for each of these problems.

An instrument can be reliable but not valid. For example, an instrument may consistently or reliably measure the same concept over and over, but it may not be the concept in which one is interested. To be valid, however, an instrument must be reliable. If an instrument fails to measure consistently the same concept, it is not valid, because one cannot be sure it is measuring what one wants it to measure.

Also of concern is that the instrument has good sensitivity and specificity ( Connors & Volk, 2003 ). Sensitivity refers to the instrument’s ability to identify correctly someone with an alcohol or drug problem (called true positives). Clinicians want to avoid instruments that are likely to classify an individual as having a substance use disorder when he or she does not have such a problem (false positives). The professional also tries to select instruments that have high specificity. They maximize the likelihood that people who do not have alcohol or drug problems will be correctly classified (true negatives), and they minimize the likelihood that people who have alcohol or drug problems will be misclassified as not having such a problem (false negatives).

Unfortunately, as sensitivity increases, specificity is likely to decrease and vice versa. One key to selecting appropriate instruments is in knowing the prevalence of the problem in the population. For example, sensitivity is greater when there is a greater likelihood of a problem occurring in a given population group (see  Lanier & Ko, 2008 ). In a study using the Brief MAST to detect alcoholism in three groups (a general population sample, general medical patients, and people in inpatient alcoholism treatment),  Chan and colleagues (1994)  found that sensitivity was lowest for the general population sample, “probably because most of the B-MAST questions deal with severe alcohol problems, and they are not sufficiently sensitive to detect those who drank heavily but who had not yet developed these alcohol problems” (p. 695). Similarly,  Heck and Williams (1995)  found that the CAGE may not be as sensitive in identifying problem drinking among college students, especially women, as it generally is with adults.

To improve sensitivity and specificity of instruments with various populations, changes may be required in cutoff scores or in how items are weighted ( Fleming & Barry, 1989 ,  1991 ). Wording changes may also provide more valid responses. Research helps to clarify whether modifications are useful. It may also be that another instrument is better suited to the population of interest. Various studies have compared the utility of the commonly used screening instruments, and some are more easily administered or more accurate with various types of clients in particular types of setting than others (see  Connors & Volk, 2003 ). Staff, however, may be unaware of the psychometric properties of the instruments they routinely use. In selecting appropriate instruments, clinicians are advised to consult the available literature and to be mindful of the caveats discussed in this chapter.

Clinicians are concerned about selecting instruments with good psychometric properties, not only in screening and assessment but also in other situations such as measuring the client’s progress during and after treatment and in evaluating the effectiveness of chemical dependency treatment programs. Factors such as the client’s ability to recall past behaviors or events can affect accurate reporting. Questions that are ambiguous or poorly worded also present a problem.

Professionals also want to know if an instrument has been validated on the populations of interest to them. Many instruments have been validated on men. Some work has been done to develop instruments that are more sensitive to detecting alcohol problems in women. For example,  Russell (1994)  developed the TWEAK by using some items from other instruments, eliminating others, and making wording changes that better reflect the situation of women. For example, asking women whether they have had fistfights may not accurately reflect the drinking-related behavior they tend to exhibit. The TWEAK was developed to screen for problem drinking during pregnancy, but it may also be useful with women in other situations ( Chan, Pristach, Welte, & Russell, 1993 ).

Another issue is whether the instrument has been tested with members of various ethnic and cultural groups. Language may be a particular concern. Terms commonly used by one ethnic group may have no meaning or a different meaning for other ethnic groups. Some efforts have been made to develop instruments that are sensitive to specific cultural groups (see, for example,  Carise & McLellan, 1999 ), but instruments that are valid across ethnic groups are particularly useful. Language can also be a problem when an instrument is used with individuals from different age cohorts, since words can take on different meanings over time. Some instruments are designed specifically for use with adolescents and others with adults. Items should be relevant to the client’s age group. For example, an adult may be asked about job and family responsibilities, whereas a child or adolescent may be asked about school.

Many of the instruments discussed so far rely on the client’s self-report. Many of them are also face valid, because they clearly ask clients about their alcohol or drug use. When using a face-valid instrument, what confidence does one have that clients are telling the truth about their behavior? When asked about the amount of alcohol or drugs they consume or whether they have had an alcohol-related blackout or lost a job due to drug use, clients can easily lie, but are they likely to do this?

Based on research to determine the reliability and validity of clients’ self-reports, many think that clinicians can have confidence in them ( Fuller, 1988 ;  Hesselbrock, Babor, Hesselbrock, Meyer, & Workman, 1983 ;  NIAAA, 1990 ). Some also believe that direct questions about substance use “provide the logical basis for one to evaluate with the assessed person their alcohol and drug consumption and its consequences” ( Svanum & McGrew, 1995 , p. 212). Some researchers have correlated clients’ self-reports with information from other sources, such as collateral contacts and laboratory (medical) tests, and have found good agreement among them.  Fuller (1988)  agrees that the balance of evidence favors their usefulness. He also notes that some studies raise serious enough questions that self-reports should be used in combination with other evidence to gain the most accurate picture of the client’s problems and functioning.  Skinner (1984)  describes the situations or conditions that influence the validity of clients’ self-reports. These factors include whether the client is detoxified and psychologically stable at the time of the assessment, the rapport established by the interviewer with the interviewee, the clarity of the questions asked, whether the client knows that his or her responses will be corroborated with other sources of information (particularly laboratory tests [ NIAAA, 1993 ]), and the degree of confidentiality that can be promised to the individual.

Hesselbrock and colleagues (1983)  also suggest that the “demand characteristics of the situation” affect the accuracy of client self-reports. For example, individuals who have little to lose from reporting problem behaviors accurately are more likely to do so. In many situations in which alcohol- and drug-dependent individuals are found, such as criminal justice or child welfare settings, this is not the case. A diagnosis of chemical abuse or dependence may have serious consequences for them. In these cases, it may be particularly important for the clinician to utilize additional sources of information to obtain a complete picture of individuals’ alcohol and drug use and any related problems in order to serve them appropriately.

There has been an interest in the use of less obtrusive (i.e., nonface-valid) instruments, such as the MacAndrew scale and the SASSI, in situations where demand characteristics might inhibit clients from giving accurate responses to face-valid questions. Even when less obtrusive measures are used, ethical, professional conduct generally requires that clients be told the purpose of the screening or assessment in which they are participating.

Diagnosis

For those individuals who screen positive, the next step is often to determine if there is sufficient evidence to confirm a diagnosis of a substance use disorder. Ideally, diagnosis is accompanied by a multidimensional, biopsychosocial assessment, which includes not only an in-depth understanding of clients’ alcohol- and drug-related problems but also their strengths, support systems, and other factors that may help promote recovery.

Various authors have recounted the history of attempts to reach agreement on the criteria needed to define and diagnose alcohol and drug problems (see, for example, Alcohol Health & Research World 15[4], 1991; 20[1], 1996). In the last few decades, considerable progress has been made in helping clinicians and researchers grapple with these issues. An important step was the work of the Criteria Committee of the National Council on Alcoholism (NCA), now the National Council on Alcoholism and Drug Dependence (NCADD). In 1972, it simultaneously published “Criteria for the Diagnosis and Treatment of Alcoholism” in the American Journal of Psychiatry and Annals of International Medicine.

Today, the criteria of the American Psychiatric Association ( APA, 2000 ) and the World Health Organization ( WHO, 1992 ) are the most widely used diagnostic tools in the field.  Edwards and Gross’s work (1976)  played an important role in the APA and WHO’s efforts to define alcohol dependence. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) delineates the current APA criteria for diagnosing substance (alcohol and other drug) use disorders. The WHO’s tenth edition of the International Classification of Diseases (ICD-10) contains its current criteria for alcohol and drug disorders.  Table 5.1  compares the APA’s criteria for alcohol dependence and abuse with the WHO’s criteria for alcohol dependence and harmful use of alcohol, respectively. In the United States, the DSM-IV-TR is widely used to diagnose substance use disorders and other mental disorders. Over the years, substantial changes have been made in DSM criteria for substance use disorders. For example, tolerance or withdrawal symptoms are no longer required for a diagnosis of dependence.

As another example from the DSM-IV-TR,  Figure 5.3  contains its descriptions of cocaine abuse and dependence. The DSM-IV-TR also contains descriptions and diagnostic criteria for other types of substance use disorders (amphetamines, cannabis, opioids, etc.) and for substance-induced disorders (e.g., intoxication, withdrawal, psychosis, sleep, mood, anxiety, sexual dysfunction, etc.).

Professionals in the United States are often required to use DSM diagnoses to request third-party (insurance) payments for treating mental health problems, including substance use and dependence. Interview protocols ( First, Spitzer, Gibbon, & Williams, 1997 ) and study guides( Fauman, 2002 ) are available to assist in applying the DSMdiagnostic criteria.

A fifth edition of the DSM is being developed. Though not yet finalized, the proposed criteria are based on clinical experience and research and may differ in many ways from the current criteria. For example, given that research indicated that the reliability of the abuse diagnosis was much weaker than the dependence diagnosis, the recommendation is to replace dependence and abuse with a single diagnosis of substance use disorder. The diagnosis of substance use disorder would be specified as either moderate or severe depending on whether two to three or four or more criteria are met, respectively. The idea that alcohol and other drug problems fall along a continuum has been suggested for some time. Another significant proposed change is to add a new criterion described as “craving,” given that it is a common clinical symptom or indicator of a substance use problem that is often categorized as severe( American Psychiatric Association, 2010 ).

TABLE 5.1 Comparison of the Diagnostic Criteria for Alcohol Dependence and Alcohol Abuse or Harmful Use in Two Diagnostic Schemes: The ICD-10 a and the DSM-IV-TR b

ICD-10	DSM-IV-TR
Comparison of Criteria for Alcohol Dependence
aFrom World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health 0rganization, 1992). Reprinted with permission of the World Health 0rganization. bReprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Copyright 2000 American Psychiatric Association.
Symptoms of Alcohol Dependence
Essential: Drinking or a desire to drink; the subjective awareness of compulsion to use is most common during attempts to stop or control drinking. At least three of the following: 1. Evidence of tolerance to the effects of alcohol. 2. A physiological withdrawal state (characteristic alcohol withdrawal syndrome or drinking to relieve or avoid withdrawal symptoms). 3. Difficulties in controlling drinking behavior in terms of onset, termination, or levels of use. 4. Progressive neglect of alternative pleasures or interests because of drinking, increased amount of time to obtain or to drink alcohol, or to recover from its effects. 5. Persisting in drinking despite clear evidence of harmful consequences which may be physical, psychological, or cognitive. 6. A strong desire or compulsion to drink. Also a consideration: a narrowing of the repertoire of drinking patterns (e.g., drinking in the same way, regardless of social constraints that determine appropriate drinking behavior).	A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by three or more of the following: 1. Tolerance defined as (a) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect or (b) markedly diminished effect with continued use of the same amount of alcohol. 2. Withdrawal, as manifested by (a) the characteristic alcohol withdrawal syndrome or (b) alcohol or a closely related substance taken to relieve or avoid withdrawal symptoms. 3. Drinking in larger amounts or over a longer period than intended. 4. Persistent desire or unsuccessful efforts to cut down or control drinking. 5. A great deal of time spent obtaining alcohol, using alcohol, or recovering from its effects. 6. Important social, occupational, or recreational activities given up or reduced because of drinking. 7. Continued drinking despite knowledge of a persistent or recurring physical or psychological problem caused or exacerbated by alcohol use.
Duration Criteria for Alcohol Dependence
At least three of the above criteria have been met during the previous year.	Three or more symptoms have occurred at any time in the same 12-month period.
Specifiers for Alcohol Dependence
None.	With physiological dependence. Evidence of tolerance or withdrawal (i.e., symptoms 1 or 2 above are present). Without physiological dependence. No evidence of tolerance or withdrawal (i.e., neither symptom 1 nor 2 is present).
Course Modifiers or Specifiers for Alcohol Dependence
Currently abstinent. Currently abstinent, but in a protected environment. Currently on clinically supervised maintenance or replacement regime. Currently abstinent, but receiving aversive or blocking drugs (e.g., disulfiram). Currently drinking. Continuous drinking. Episodic drinking.	Remission Specifiers (Do not apply if individual is on agonist therapy or in a controlled environment.) Early remission. 1. Early full remission. No criteria for abuse or dependence met in last 1 to 12 months. 2. Early partial remission. Full criteria for dependence not met in last 1 to 12 months, but at least one criterion for abuse or dependence met, intermittently or continuously. Sustained remission. Twelve months of early remission have passed. 1. Sustained full remission. No criterion for abuse or dependence met at any time in past 12 months or longer. 2. Sustained partial remission. Full criteria for dependence not met in past 12 months or longer, but at least one criterion for abuse or dependence met. Additional Specifiers No criteria for alcohol dependence or abuse have been met for at least one month. On agonist therapy. In a controlled environment.
Comparison of Criteria for ICD-10 Harmful Use of Alcohol and for DSM-IV-TR Alcohol Abuse
Symptoms
Harmful Use of Alcohol Clear evidence that a pattern of alcohol use was responsible for: 1. Actual physical damage to the user. or 2. Actual mental damage to the user.	Alcohol Abuse A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one or more of the following: 1. Recurrent drinking resulting in failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance). 2. Recurring drinking in situations in which it is physically hazardous (e.g., driving an automobile). 3. Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct). 4. Continued alcohol use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments, physical fights).
Duration Criteria for Harmful Use and Alcohol Abuse
None.	One or more symptoms have occurred at any time during the same 12-month period.
Exclusionary Criteria Related to Alcohol Dependence
Does not presently meet criteria for alcohol dependence, a psychotic disorder, or other drug- or alcohol-related disorder.	Never met criteria for alcohol dependence.

Sources: From ICD-10. Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines, World Health Organization, 1992, is reprinted by permission of WHO. From The Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision, Copyright © 2000 American Psychiatric Association. Reprinted with permission of the American Psychicatric Association.

FIGURE 5.3

Cocaine Dependence and Abuse

Cocaine Dependence

Cocaine has extremely potent euphoric effects, and individuals exposed to it can develop dependence after using cocaine for very short periods of time. An early sign of Cocaine Dependence is when the individual finds it increasingly difficult to resist using cocaine whenever it is available. Because of its short half-life, there is a need for frequent dosing to maintain a “high.” Persons with Cocaine Dependence can spend extremely large amounts of money on the drug within a very short period of time. As a result, the person using the substance may become involved in theft, prostitution, or drug dealing or may request salary advances to obtain funds to purchase the drug. Individuals with Cocaine Dependence often find it necessary to discontinue use for several days to rest or to obtain additional funds. Important responsibilities such as work or child care may be grossly neglected to obtain or use cocaine. Mental or physical complications of chronic use such as paranoid ideation, aggressive behavior, anxiety, depression, and weight loss are common. Regardless of the route of administration, tolerance occurs with repeated use. Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoric mood, can be seen and are likely to enhance craving and the likelihood of relapse. The overwhelming majority of individuals with Cocaine Dependence have had signs of physiological dependence on cocaine (tolerance or withdrawal) at some time during the course of their substance use. The designation of “With Physiological Dependence” is associated with an earlier onset of dependence and more cocaine-related problems.

Cocaine Abuse

The intensity and frequency of cocaine administration is less in Cocaine Abuse as compared with dependence. Episodes of problematic use, neglect of responsibilities, and interpersonal conflict often occur around paydays or special occasions, resulting in a pattern of brief periods (hours to a few days) of high-dose use followed by much longer periods (weeks to months) of occasional, non-problematic use or abstinence. Legal difficulties may result from possession or use of the drug. When the problems associated with use are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to obtaining and administering cocaine, a diagnosis of Cocaine Dependence rather than Cocaine Abuse should be considered. However, since some symptoms of tolerance, withdrawal, or compulsive use can occur in individuals with abuse but not dependence, it is important to determine whether the full criteria for dependence are met.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Copyright 2000 American Psychiatric Association.

A historical controversy in the field of treatment for alcohol problems centered on whether identifying and treating the underlying causes of alcoholism (e.g., various psychological problems) would result in remission of alcohol problems. This approach has not proven satisfactory for two reasons. First, scientists have yet to discover the exact etiologies of substance use disorders, and second, even if the underlying causes were known, substance use disorders often become problems in their own right. Our discussion of diagnosis generally refers to substance abuse or dependence as a major or primary problem presented by the client, requiring specific treatment. The reader may have also encountered the term secondary diagnosis. In 1972, the Criteria Committee of the NCA (1972a,b) wrote:

Reactive, secondary, or symptomatic alcohol use should be separated from other forms of alcoholism. Alcohol as a psychoactive drug may be used for varying periods of time to mask or alleviate psychiatric symptoms. This may often mimic a prodromal [early] stage of alcoholism and is difficult to differentiate from it. If the other criteria of alcoholism are not present, this diagnosis must be given. A clear relationship between the psychiatric symptom or event must be present; the period of heavy alcohol use should clearly not antedate the precipitating situational event (for example, an object loss). The patient may require treatment as for alcoholism, in addition to treatment for the precipitating psychiatric event.

It may even be that excessive alcohol or drug use that developed following a traumatic event, such as loss of a loved one, may remit without specialized substance abuse treatment once an adjustment is made to the new life circumstance. But this is different from the situation in which alcohol or drug use itself has become a problem for the individual. Take, for example, the case of an individual who blames his diagnosis of alcohol dependence on a divorce that occurred ten years ago. Although it may be true that his drinking escalated at that time, alcohol dependence itself has become a problem, requiring it to be addressed as such. Exploring the issues that caused the client to fixate on his divorce may also be helpful at some point, but this alone is unlikely to resolve his years of alcohol problems. Many practitioners believe that treatment must first focus on arresting the alcohol dependence.

Today, we recognize that a substantial number of people with mental disorders also have diagnoses of alcohol or drug disorders. Although their drinking or drug use may have been precipitated by the desire to relieve symptoms of mental disorders (hallucinations, anxiety, etc.), many of them require treatment for substance use disorders as well as treatment for mental illness. The subject of dual or co-occurring diagnoses has become of such importance that we devote  Chapter 13  to it.

Assessment

The APA and the WHO’s diagnostic criteria are important in establishing whether an individual has a substance use disorder, but more information is needed to plan for the client’s treatment. The DSM-IV-TR ( APA, 2000 ) recommends a multiaxial assessment, which also considers factors such as the individual’s cognitive abilities, medical condition, psychosocial and environmental problems, and overall level of functioning.

Addiction Severity Index

A multidimensional assessment tool widely used in the chemical dependency field is the Addiction Severity Index (ASI) ( McLellan et al., 1985 ). The ASI is a structured interview accompanied by a numerical scoring system to indicate the severity of the patient’s or client’s problems in seven life areas: alcohol, drugs, vocational, family and social supports, medical, psychological or psychiatric, and legal. Chemical dependency professionals and other human service professionals who have been trained in its use can administer the ASI. The ASI has a follow-up version that has also contributed to its use in treatment and research to measure client progress and to assess the effectiveness of treatment programs. Similar instruments for use with adolescents have also been developed ( Friedman & Utada, 1989 ;  Kaminer, Wagner, Plummer, & Seifer, 1993 ).

Drug Use Screening Inventory

Another tool designed to assess the severity of adults and adolescents’ problems on multiple dimensions and to rank these problems is the Drug Use Screening Inventory-Revised (DUSI-R) ( Tarter & Hegedus, 1991 ;  Tarter & Kirisci, 2001 ; also see  Allen & Wilson, 2003 ). The 10 domains of the DUSI-R are frequency of and degree of involvement in drug and alcohol use (including drug preference), behavior patterns (such as anger and self-control), health status (including accidents and injuries), psychiatric disorder, social competence, family system, school performance/adjustment, work adjustment, peer relationships, and leisure/recreation. The DUSI-R contains 159 items requiring yes or no answers.

The DUSI is used in three phases. First, each domain is assessed using the basic assessment instrument. This instrument is written at a fifth-grade level and takes about 20 minutes to complete as a paper-and-pencil test or by computer, and it can be read to those with lower reading levels. Second, instruments are available to assess further those areas that appear to be problematic in order to provide a more comprehensive evaluation. Third, the information from stages one and two is used to develop an individualized treatment plan for the client.

Versions of the DUSI-R are available to provide information for the past week, past month, and past year. There are no scores that distinguish between types of treatment needed; instead, this is left to clinical judgment once the DUSI-R and other assessment information is compiled to give a full picture of the client’s needs. Like the ASI, the instrument may be used to chart the client’s progress, and client information can be aggregated for program evaluation studies. The DUSI-R’s developers report that it has good ability to classify adults and adolescents with DSM substance disorders and that it also has good ability to identify those with no psychiatric disorders.

The information obtained from screening, diagnosis, and assessment is used to determine the type of substance abuse or dependence treatment the client needs.  Chapter 6  describes the components of the chemical dependency treatment system, indicating clients’ situations that are likely to warrant the various services. Since many alcoholics and addicts initially seek help for marital, family, job, legal, or health problems rather than for alcohol or drug problems, it is incumbent on helping professionals from all disciplines and in various treatment settings to be knowledgeable about screening, diagnosis, and assessment for chemical abuse and dependency problems. Similarly, tools such as the ASI are important to professionals in the chemical dependency field because they are concerned with the client’s overall quality of life. A unidimensional approach indicates that the treatment goal of abstinence (or reduced use) is expected to result in improvement in other areas of the client’s life, whereas a multidimensional approach suggests that each of the client’s major problems be targeted for treatment since abstinence (or reduced use) alone may not resolve them ( Babor, Dolinsky, Rounsaville, & Jaffe, 1988 ;  McLellan, Luborsky, Woody, O’Brien, & Kron, 1981 ). The multidimensional or systems view of assessment and treatment seems to have taken precedence over the view that chemical dependency is a unitary phenomenon and that chemical dependency professionals need be concerned only about clients’ alcohol and drug problems ( Babor et al., 1988 ;  Callahan & Pecsok, 1988 ;  Pattison, Sobell, & Sobell, 1977 ).

Taking a Social History

Taking a client’s social history is particularly important because it is the type of assessment that exemplifies the systems or ecological perspective of this book. *  Our discussion is intended to alert the new professional to some of the issues involved in doing a thorough assessment, focusing on the client’s strengths as well as problems. There are many formats for doing social histories, from checklists to structured interviews to more open-ended formats. The social history outline found in  Figure 5.4  can be used to structure an assessment or intake interview with adults who recognize that alcohol and/or drugs are a problem in their lives. A skillful interviewer may also be able to use this tool to reduce defensiveness in clients who are less willing to discuss their alcohol or drug use and to begin to engage the client in the treatment process and increase motivation for change (see  Donovan, 1988 ;  Miller, 1985 ). Although not exhaustive of all the avenues that can be explored with a client, the topics and questions suggested in the outline can help the interviewer capture information both about problems in the client’s life and about the assets the client brings to the recovery process. The social history format is flexible and can be adjusted depending on the client and treatment setting. Sometimes, a comprehensive intake interview or social history is done at an initial session. In other cases, the material is obtained over several sessions. Clients may initially give limited answers to questions but reveal more information over time as comfort and trust with the treatment professional increases. Assessment is not a single event; it takes place throughout the treatment process as clients’ needs and circumstances change.

* Thanks to William J. McCabe, who taught me a great deal about many of the elements of the social history.

FIGURE 5.4 The Social History as it Relates to Drinking and Drug Use

I. Education

A. How long did the client stay in school?

B. How did the client like or feel about school?

C. Did the client do well in school?

D. Did the client have a history of alcohol and/or other drug use or abuse during the school years?

E. Did the client have friends and close relationships during the school years? If so, were these individuals alcohol or drug users/abusers?

F. What work is the client educated to do?

II. Employment

A. What is the client’s current job or when did the client last work?

B. What other jobs has the client held?

C. How often has the client changed jobs?

D. What is the client’s favorite type of work?

E. Has the client experienced job difficulties? If so, what seems to be the cause of these problems?

F. If the client is not working, is he or she obtaining financial support from other sources?

III. Military History (if applicable)

A. If not currently in the military, what type of discharge did the client receive?

B. What was the client’s last rank in the military?

C. What were the client’s patterns of socialization in the military?

D. How long did the client remain in the military?

E. If the client experienced problems in the military, were they related to alcohol, other drug use, or other factors?

IV. Medical History

A. Does the client have current or past medical problems?

B. Has the client ever been hospitalized for medical problems?

C. Are past medical records available?

D. Is the client currently taking medications or has the client taken medications in the past?

E. Has the client abused prescription or nonprescription drugs?

F. Are any of the client’s medical problems directly related to or exacerbated by alcohol or other drug use?

G. Will participation in treatment for alcohol or drug problems require any accommodation for medical disabilities?

V. Drinking and Drug Use History

A. If the client uses drugs, what drugs does he or she use; if the client drinks alcohol, what beverages does the client drink, and has the client consumed products containing alcohol that are not meant for human consumption?

B. How often does the client consume alcohol or other drugs?

C. How much alcohol and/or drugs does the client use?

D. What is the client’s drinking or drug use pattern (daily, weekend, periodic, etc.)?

E. When did the client’s drinking or drug use begin?

F. Does the client give a “reason” for his or her drinking or drug use?

G. Has the client experienced periods of abstinence?

H. Has the client experienced blackouts or other indications of chemical abuse problems?

I. Has the client experienced withdrawal symptoms from alcohol or other drugs?

J. Has the client ever received treatment for a drinking or other drug problem?

K. Are past treatment records available?

VI. Psychological or Psychiatric History

A. Does the client express feelings of being tense, lonely, anxious, depressed, etc.?

B. Has the client ever contemplated, threatened, or attempted suicide?

C. Has the client received any counseling or psychiatric treatment on an outpatient basis?

D. Has the client ever had a psychiatric hospitalization?

E. Are records of past treatment available to determine the exact nature of the problem and treatment received?

F. Will participation in treatment for alcohol or drug problems require any accommodation for mental disabilities?

VII. Legal Involvement (if applicable)

A. Is the client currently on probation or parole or incarcerated?

B. What types of charges or other legal problems has the client had?

C. Were any legal charges related to alcohol or other drug use directly (sale, possession) or indirectly (e.g., embezzlement, theft)?

D. Does the client have any charges pending? If so, what are they, and does the client believe that chemical dependency treatment will result in reduced legal penalties?

E. If the client was arrested for DWI or DUI, what was his or her blood-alcohol level or are other tests results available indicating the presence of drugs?

VIII. Family History

A. What are the drinking and drug use habits of members of the client’s family of origin (mother, father, grandparents, siblings, aunts, uncles, etc.)?

B. Do members of the client’s family of origin have alcohol or other drug problems?

C. What were the attitudes toward drinking alcohol and other drug use in the client’s family of origin?

D. How does the client describe his or her relationship with family of origin members?

E. Was there a history of psychological or physical (including sexual) abuse in the family? What was the client a direct victim?

F. What is the client’s current relationship with family members?

IX. Relationship with Spouse, Children, and Other Significant Individuals

A. What is the client’s current marital status and marital history?

B. If the client has a spouse/partner and/or children, what is the quality of the relationship with them?

C. What are the spouse/partner’s or children’s drinking and drug-taking habits?

D. Are the client’s spouse/partner and/or children experiencing problems (psychological or physical abuse, etc.)?

E. What are the client’s living arrangements?

F. What is the extent of the client’s other social relationships?

X. Religion/Spirituality

A. In what religious or spiritual tradition, if any, was the client raised?

B. Does the client have a particular religious preference or spiritual beliefs at this time?

C. Does the client view his or her religion or spiritual beliefs as a source of strength or a source of difficulty in his or her life?

XI. Why the Client is Seeking Help Now

(e.g., are there legal, medical, family, work, or other pressures to do so?)

In conducting a social history, the interviewer determines which questions to ask at a given time and the order of the questions. In approaching each section of this social history with the client, the interviewer might begin by commenting not only on the type of information that might be gathered but also on the reasons for gathering it. Often, the social history starts with information considered to be least threatening to the client. The sections on education and employment may be good starting points. Basic questions about how much education the client has had and whether the client has professional or vocational education are generally considered routine and are usually easily answered by clients without resistance.

Education

School adjustment may be a useful avenue to explore, especially for younger clients, as it may be particularly relevant to their current situation. With older clients, the interviewer may ask whether he or she liked school, did well, and fit in, or if school was a frustrating or unsatisfactory experience. Did the client initiate alcohol and/or other drug use or abuse in primary or secondary school or in college? Were his or her friends involved in alcohol and drug use in the same way? These questions may help establish the time frame and circumstances during which alcohol or drug use first became a problem. If the client has no high school diploma or no college or vocational education and wishes to pursue further education, the chemical dependency professional may note the client’s need for a referral to a general equivalency diploma (GED) program or other educational or vocational program. If the client did well in school and has substantial education, these may be noted as assets to recovery.

Employment

Questions about employment often follow logically after questions about education. Is the client currently employed and is the client’s job secure or has it been threatened by substance abuse or dependence? During assessment interviews, individuals (such as those referred by an employee assistance program or by the correctional system) may deny employment problems related to alcohol or drug use. The pattern of employment—whether it is stable or erratic—is important to note. An erratic employment history is not necessarily the result of a substance use disorder, but it may be an indication of it or other problems in the client’s life. Discussion of employment may provide an opportunity for the assessment specialist to help clients identify how alcohol or drug use has negatively affected their work.

Another clue to problems may be the client’s employment in a job that is well below his or her educational level. For example, an individual with a graduate degree may be working in a convenience store. Perhaps this work is what the individual prefers, perhaps this is the only work available, or perhaps a substance use disorder has interfered with other employment. Seeming incongruities in the individual’s life such as these can be explored to help determine if substance abuse or dependence is a problem.

The client may have a job that is an obstacle to recovery. An obvious example is working as a bartender, where constant exposure to alcohol presents a problem for the client. Or perhaps the individual spends long periods on the road alone and is used to going to bars at night to relieve loneliness or boredom. Some clients frequently find themselves in situations where alcohol or perhaps other drug use is common or expected. For some of these individuals, learning how to engage in alternative activities or assertiveness training to learn how to refuse drinks or drugs may prove useful. For others, a key to attaining sobriety may include employment changes. A referral to a vocational rehabilitation agency, an employment counselor, or an employment agency may be appropriate. These referrals may be made at the time of the intake or assessment interview or at a later date, depending on the client’s circumstances.

Some clients are in immediate need of a job. Professionals who work with clients who are homeless or living in very impoverished circumstances generally know the street corners or programs in town where a client can try to get a day labor job, or they know employers who hire and pay individuals by the day. The professional’s interest in the whole client, not just the client’s substance abuse or dependency problem, is reflected in addressing employment concerns. Productive employment can be a useful tool in maintaining sobriety. For some clients, current employment may be identified as an asset. For example, an individual referred by an employee assistance program may have a job that he or she is anxious to keep. The interviewer may also ask questions about work hours or work habits to determine whether the client is currently working to the detriment of other aspects of his or her life.

When clients are not working, it may be appropriate to inquire about their current means of support. They may be receiving public assistance or Social Security payments, or they may need a referral to apply for these benefits. Some clients may be getting help from family or friends, or they may be dealing drugs or engaging in other criminal activity to support themselves.

Military History

Questions about military service are often not asked unless the client is currently in the service or is in a Veterans Administration facility. However, these questions may be important, because young adults may be introduced to alcohol and other drugs while in the military. A problematic military history may have been the result of alcohol or drug problems. Questions that might be asked to probe into this area involve the rank or ranks the client held in the military and the type of discharge the individual received. For example, being demoted in rank or receiving a medical, general, administrative, or dishonorable discharge may have been a consequence of alcohol or drug problems.

Medical History

An obvious reason that questions about medical problems are asked is to determine if they may be related to substance use. The client may not have made a connection between his or her medical problems (e.g., sores, gastritis, or neuropathy) and alcohol or other drug use. Some medical problems are not caused by substance use, but alcohol and drug use may be contraindicated if the client has a particular condition(e.g., diabetes or epilepsy). Another reason to ask these questions is to determine if the client is receiving appropriate care for any current conditions. If the client does not have personal resources to obtain medical attention, the interviewer may act as a referral source to community clinics, the local health department, or other services, although many communities lack the resources to provide anything but emergency medical care to those who do not have health insurance.

Also important are any prescribed or over-the-counter (OTC) medications the client is taking. Some clients are taking medication but do not understand what it is, only that the doctor told them to take it. Many are unaware of the adverse consequences that alcohol can have when combined with common OTC medications such as ibuprofen, acetaminophen, and aspirin, or the additive effects of combining alcohol with other sedative drugs ( Weatherman & Crabb, 1999 ) or the contraindications of combining illicit drugs with OTCs or prescribed medications.

An important reason health questions are asked, especially in inpatient and residential programs, is for staff to be prepared if the client experiences medical problems. For example, a history of epilepsy would be of concern in order for staff to be prepared for seizures, and it is important to know if a history of seizures is related to epilepsy or to alcohol or drug withdrawal. There is a growing body of literature on those who are dually diagnosed with chemical dependency problems and major physical disabilities (see  Chapter 13 ).

A release or consent form signed by the client is generally needed to obtain information about prior health history and medical treatment. This information should be requested if it would be useful in assisting the client in the chemical dependency treatment setting.

Legal History

Questions about the client’s legal problems are also important. Many referrals to chemical dependency treatment programs are motivated by the legal system. A brush with the law may help the client confront a chemical dependency problem, or a client may seek treatment in the hope of obtaining a lighter or deferred sentence. Probation and parole officers and attorneys frequently refer clients to chemical dependency programs. The courts may routinely require those convicted of a driving while intoxicated (DWI) or DUI offense to submit to a screening or assessment to determine whether they have an alcohol or drug problem.

Often, a client admits to getting into legal difficulties as a result of using alcohol or drugs but denies an inability to control alcohol or other drug use. An important clue to a drinking problem in these cases may be blood-alcohol level (BAL) or blood-alcohol content (BAC).A breathalyzer or intoxilizer is frequently used to measure BAL or BAC, typically following arrest on suspicion of DWI or DUI. A high level maybe an indication of tolerance to alcohol or alcohol dependence. For example, a person with a 0.20 percent BAL may deny a problem, but 0.20 is at least twice what is commonly referred to as the “legal limit” of 0.08 in most states. Most people would be unable to drive at a 0.20 level, yet those with a high tolerance may be able to do so despite its recklessness.

Asking how much alcohol was consumed before the arrest may be another clue to the client’s candidness in responding to questions. When an individual says she had two cocktails but her BAL is 0.20, something is amiss. Two cocktails (of the type typically served in a bar) would not produce such a high BAL. Sometimes a blood test is used to determine BAL or the presence of other drugs. In accidents where a person is seriously injured and is taken to the hospital, the use of a blood test is common. Previous DWI or DUI arrests or other history of alcohol- or drug-related arrests are also strong clues to consider. Most people would not make the mistake of getting a second DWI or DUI because the consequences can be severe. The person with an unrecognized problem is far more likely to make this costly misjudgment.

Other common types of alcohol- and drug-related arrests are public intoxication (in locations where this offense is still a crime), disorderly conduct, and offenses related to the possession and sale of controlled substances. Transients who have chemical dependency problems are frequently arrested for vagrancy. Arrests for family violence may be due to alcohol abuse. White-collar crime, such as embezzlement and forgery, may also result from having a drug habit. With the advent of drug screening in the workplace, urinalysis, previously used most by the criminal justice system and in therapeutic communities, has become an increasingly common tool to identify job applicants or employees who use illicit drugs.

Clients may bring other legal problems to the interviewer’s attention, such as fears that past behavior may result in prosecution if discovered. Other legal matters worrying clients may be how to deal with an abusive partner or civil matters such as eviction, child custody, and child support. Referrals to legal services may help clients address these problems so that they can better avail themselves of treatment.

Drinking and Drug History

Naturally, the individual’s drinking and drug history are paramount in conducting an assessment for substance use disorders. What psychoactive substances has the client used in his or her life? What drug or drugs is the individual currently using, including frequency and amount of use? Many clients have problems related to alcohol and drugs or more than one drug. Clients may also be asked if they have ingested technical products that contain alcohol but are not meant for human consumption (e.g., rubbing alcohol, after-shave lotion, Sterno, etc.) or sniffed or inhaled other household products (e.g., paint, glue, etc.). What problems has the individual experienced as a direct result of alcohol or other drug use, such as blackouts or violent behavior or withdrawal symptoms like tremors, seizures, hallucinations, or delirium tremens?

In obtaining information from or about clients who are not detoxified, it is especially helpful to know about previous withdrawal symptoms that the client has experienced. Such information may indicate the need for immediate referral to a detoxification program and can be very helpful to the medical staff assisting the client through withdrawal. The client may be intoxicated or otherwise unable to provide this information, and others who know the information may not be available. This is frequently the case when a transient individual is brought to a hospital emergency department or to a community detoxification center (see  Chapter 6 ).

It is also important to know if the individual has made attempts to stop using alcohol or other drugs in the past and if he or she has had periods of abstinence (no alcohol or drug use, often referred to as “sober time” or being “clean”). These periods may also indicate that the individual is an alcohol or drug abuser, since others usually do not need to make special efforts at abstinence. Periods of abstinence should be considered an asset, and the chemical dependency counselor can discuss with the individual behaviors or circumstances that may have contributed to the ability to remain alcohol or drug free. Another question is whether the client has had previous treatment for alcohol or other drug problems. The client may be asked to give consent to obtain treatment records or to talk with previous treatment providers in order to provide a better understanding of his or her progress and setbacks in treatment. Information of this nature may also be helpful in determining whether the client is best served in an inpatient, residential, or outpatient chemical dependency treatment program.

A possible avenue to explore is whether the individual perceives that his or her alcohol or drug problems were precipitated by particular events or circumstances. This may seem like an unusual question since no one really knows what causes substance use disorders. Asking the question is not done to give the client an opportunity to place blame on some internal or external factor. It is done to understand better the client’s own perception of his or her substance abuse or dependence. This is a reflection of the principle of “starting where the client is.” Many clients need help in understanding the dynamics of chemical abuse and dependence. Remember the client mentioned earlier who blamed his drinking on a divorce that occurred ten years ago? He may be correct in identifying that drinking or other drug use escalated at that point, but he is probably incorrect if he thinks that reuniting with his former spouse will solve the problem. The professional taking the social history may make note, however, that this will be an important point to which to return with the client. Additionally, knowing events that generally precede episodes in which the client drinks or uses drugs may help to establish plans that can avert relapse (see  Chapter 6  regarding relapse).

Psychological or Psychiatric History

Psychological or psychiatric history is yet another aspect of diagnosis and assessment. Does the client have one or more mental disorders? Of immediate concern are current and serious psychological or psychiatric problems the client is experiencing, especially thoughts or plans related to suicide. Some individuals, particularly those who have made past suicide attempts or are dependent on depressant drugs such as alcohol, are at high risk for suicide. An immediate referral for psychiatric evaluation or to an inpatient psychiatric unit may be needed. Some clients with chemical dependency problems have serious mental disorders such as schizophrenia, or they may have personality disorders or other mental illnesses (also see  Chapter 13 ).

If adequate information on psychiatric history is not available and mental health problems are suspected, a psychological or psychiatric evaluation should be obtained. An accurate diagnosis is necessary to determine the range of services the client needs and who may best treat the client. A referral to a mental health program or, where available, a program specifically for those with co-occurring chemical dependency and mental disorders may be the best alternative. Individuals with co-occurring disorders may also be directed to mutual-help or other support groups designed specifically for them.

Family History

The family history section of the assessment refers to the client’s family of origin. These questions should probably be asked after some rapport has been established because they can be particularly emotionally charged for the client. Many people who become dependent on alcohol have a parent who was dependent on alcohol (this may even be the case for both parents). It has also become more common to see families with intergenerational drug problems. If so, it is useful to know whether the client’s parent is (or was) in recovery and, if so, at what point in the client’s life this happened. Do other family members (such as siblings, aunts, uncles, and grandparents) have drinking or drug problems?

Other useful information concerns family attitudes about alcohol and drug use. Was there an intolerant attitude toward any use of alcohol? Were drinking or drug use seen as acceptable, and how was abuse of these substances viewed? To what extent were family attitudes related to particular cultural or religious beliefs (also see  Chapter 11 )? Knowing whether there was a history of psychiatric or other problems among family members may also be helpful in understanding the client’s situation.

Questions about the client’s current relationship with members of his or her family of origin are also important. Is the client in contact with other family members or estranged from them? Are family members seen as potentially supportive of the client’s recovery, or might they present obstacles by reinforcing or encouraging the client’s alcohol or other drug use? It may be appropriate to consider involving family members in the client’s treatment. How much the client is asked to reveal about his or her family of origin will depend on the treatment setting and its purpose. In a brief detoxification program, medical history is more important than family history. In an intensive inpatient or extended outpatient treatment setting, the social history may delve further into family matters.

Not so long ago, chemical dependency professionals were unlikely to ask clients questions about previous physical, sexual, and emotional abuse inflicted on them by family members or others. However, as professionals began hearing about this from clients, particularly women, it could not continue to be overlooked. These problems may surface during treatment and can present serious obstacles to recovery if not addressed appropriately. The topic of physical, sexual, and psychological abuse may or may not be broached in the initial assessment interview, depending on professional judgment. Unless the client offers this information, it may be premature to do so because it may be too distressing for the client to address very early in the process of alcohol or drug treatment. These problems may be better addressed once a relationship between client and professional has developed, and they may require referral to a qualified mental health practitioner.

Current Family and Social Relationships

Other vital questions concern the client’s relationship to any current or former spouse, other partners, or children. If the client’s sexual orientation is not clear, the professional should take care not to make an erroneous assumption about the gender of the client’s partner (also see  Chapter 12  on gay men, lesbians, and bisexual and transgendered individuals). How do the client’s significant others perceive his or her drinking or drug use? Are they aware that the client has come for help? Are they similarly engaged in alcohol or drug use, or have they pushed the client to contact the treatment program? Including significant others in the treatment process can be helpful for all parties involved. The interviewer should explore whether significant others are likely to be supportive and inquire as to whether the client wishes to involve them in treatment. Clients are often encouraged to include them, though in some cases it is not advisable (e.g., when there are concerns about retaliation from an abusive partner). In other cases, the client may be threatened with an unwanted separation or divorce, and his or her partner may wish to sever all ties rather than participate in treatment. Sometimes, child abuse or neglect becomes apparent or is suspected, or threats on a partner’s life are made and may have to be reported in keeping with state statute or the “duty to warn.”

Stable living arrangements make the process of becoming alcohol and drug free easier, but some clients have no suitable home or are living with others who have active substance use disorders. Professionals in the alcohol and drug rehabilitation fields have always worked with individuals who are drifters or find themselves with no roof over their heads. Deinstitutionalization of people with mental illness, unemployment, and lack of affordable housing in addition to alcohol and drug disorders have added to the ranks of people who need housing or residential treatment in order to make rehabilitation a viable option.

Questions about close friends, other social relationships, and involvement with organizations and associations also help to determine the extent of social supports the client has in the community. Many clients need assistance in establishing friendships with sober or “clean” individuals and with pursuing activities not centered on alcohol and drug use.

Religion and Spirituality

Religious affiliation and spiritual beliefs are addressed to determine if they may be an avenue of support and strength for the client or if they are causing the client difficulty. Some clients find solace in their religious and spiritual beliefs, and their priest, minister, rabbi, or other clergy member may be a resource to whom they turn in times of crisis. Church groups may also be of assistance to the client in recovery. In other cases, the church or religious group in which the individual has participated over the course of his or her life may hold punitive attitudes toward people with alcohol problems that have contributed to the client’s guilt or denial. Clients may also feel that if only their faith was stronger, they could overcome their problem with alcohol or drugs, and do not take other steps needed for recovery.

The role of religion and spirituality in the recovery process has become an area of empirical study. Clients who do not subscribe to a particular religion may have deeply held spiritual beliefs. More treatment providers are including the religious or spiritual dimension in the client assessment and treatment process (see  Hodge, 2001 ).

Why the Individual Is Seeking Services

Finally, if it is not clear why the individual is seeking services at this particular time, the interviewer may want to inquire about this. Many clients have abused psychoactive drugs for a long time but have not previously sought help. Is there some particular concern, such as threat of job loss, divorce, or legal consequences, that has motivated the individual to seek help at this time? Or perhaps, as the saying goes, the individual is just “sick and tired of being sick and tired.”

Initial appointments or assessment interviews may be done free of charge even by private-for-profit treatment programs as a way of encouraging people to consider some type of treatment or to encourage use of a particular program. For clients who want further services, the initial appointment usually also involves determining whether the individual has insurance or another means of paying for treatment. If the client does not have the financial resources required by the program or needs services the program does not offer, professionalism generally requires that a referral to another resource be offered.

Denial, Resistance, and Motivation for Recovery

It is probably impossible to work in a substance abuse or treatment program without hearing the terms denial and resistance during the course of the workday.  Tarter, Alterman, and Edwards (1984)  describe the ways in which the term denial has been used in the chemical dependency field:

Denial ... has frequently been used to explain an alcoholic’s failure to recognize the role of his feelings in instigating and sustaining drinking. Denial has also long been believed to reflect a conscious refusal by an alcoholic to recognize the effects of continued and excessive drinking on himself and his environment, thereby contributing to the alcoholic’s resistance to initiating treatment, as well as ensuring poor treatment prognosis. Within the rubric of psychodynamic theory, denial has been conceptualized as an ego defense, and as such is considered to be indicative of an unconscious attempt by an alcoholic to protect himself from the threatening or aversive aspects of drinking behavior. (pp. 214–215)

As a largely unconscious process, denial differs from lying or an outright attempt at deceit ( George, 1990 ).  Tarter and colleagues (1984)  propose a biopsychological interpretation of denial, suggesting that some alcoholics have a “disturbed arousal regulation process” in which they fail “to perceive or label internal cues accurately” (pp. 214–215; also see  Donovan, 1988 ). This causes them to underestimate the severity of stress in their lives, thereby promoting denial.

Everyone employs defense mechanisms to cope with life’s stresses and strains. For example, news of the death of a family member or that one has a serious illness may be initially met with denial (see  Kinney, 1996 ). In these cases, denial initially serves a protective function until the individual can begin to integrate the event and move along to the next stages of the grief process. Clearly, it is necessary to utilize some level of defenses in order to maintain healthy psychological functioning, but when one is unable to move past denial, well-being is jeopardized. This is frequently the case with the individual who has a substance abuse or dependence problem. As  Weinberg (1986)  puts it:

Denial is a way the human mind often deals with a situation involving incompatible perceptions, thoughts, or behaviors. In the case of drinking problems, the two elements are the powerful reinforcement derived from the drug and the unwanted side effects produced at the same time. The former is comprised of positive reinforcement (euphoria and energy) and/or negative reinforcement (temporary reduction of such unwanted feelings as tension, depression, self-hate, boredom, and sexual inadequacy). (p. 367)

Another function of denial is to shield substance abusers from feelings of hopelessness ( George, 1990 ).  Kinney (1996)  notes that many patients are actually unaware that their problems are a result of substance abuse.

Weinberg (1986)  and  Kinney (2000)  recommend helping clients reduce their denial gradually, since it is serving an important, protective function. A critical task of the treatment professional is to help clients recognize the relationship between their drug use and its negative consequences. To facilitate this process with cocaine abusers,  Washton (1989)  developed the Cocaine Assessment Profile (CAP), which can be useful in assessment and in addressing denial. The CAP questions about drug use and its consequences help clients understand the magnitude of their substance abuse and the need for treatment.

Family members and other loved ones are also likely to engage in denial. It is equally painful for them to recognize that someone they care about is chemically dependent. They may blame themselves for the client’s problem or they may just be plain embarrassed about the situation. Consequently, people with alcohol and drug problems and their significant others reinforce each other’s denial. In a well-known pamphlet published by  Al-Anon (1969) , Reverend Joseph L. Kellerman likened the process of denial to being on a merry-go-round, but he noted that “the alcoholic cannot keep the Merry-Go-Round going unless the others [family, friends, employers, etc.] ride it with him and help him keep it going” (p. 13). When more than one member of the family is chemically dependent, denial can be especially strong.

In addition to denial, clients and their significant others may use a variety of other defenses. These include rationalization (attempts to find reasons to explain or excuse the chemical use), projection (blaming or attacking others for problems), avoidance or evasion of discussions of chemical use, recollection of the positive effects and experiences associated with chemical use, minimization of chemical use and its effects, and repression of painful events and feelings ( George, 1990 ;  Johnson, 1973 ). But George notes that “denial is a more prominent approach, because it blocks the need for the use of the other defense mechanisms entirely” (p. 36). It is also important to remember that the individual’s defensiveness may result in behaving in grandiose, aggressive, and belligerent ways when often his or her feelings, especially during periods of sobriety, are actually remorse, guilt, inferiority, and helplessness.

Just as clients vary in their expression of denial and other defenses, they also vary in the extent to which they enter treatment voluntarily. Individuals who call a 24-hour crisis line asking for help with a drug problem or those who walk into a treatment program are generally considered voluntary clients. Of course, external factors may have motivated them to request help—for example, fear that their marriage or their work is suffering. Less voluntary clients may be those who have been committed or ordered to treatment through civil procedures (these laws and procedures vary by state). In these cases, family members or others have appealed to the court because the individual has refused to seek help and is in serious danger due to alcohol or other drug use. Other clients have been referred through their employer because their jobs are at stake, or their probation officer has told them to get help. These clients may recognize the problem and may participate willingly in treatment. Others may attend simply to remain employed or to fulfill the terms of their court order. Even so, there is ample evidence that some degree of pressure or coercion may be helpful in prompting treatment entry and promoting better client outcomes ( Burke & Gregoire, 2007 ;  Center for Substance Abuse Treatment, 2005 ;  Hiller, Knight, Broome, & Simpson, 1998 ;  Leukefeld & Tims, 1992 ;  National Institute on Drug Abuse [NIDA], 2009 ;  Perron & Bright, 2008 ;  Trice & Beyer, 1982 ).

Clearly, individuals differ in their willingness or ability to terminate substance use and desire to engage in the treatment process. It may take some time for treatment providers to develop rapport with clients and to help them work through their defenses, but clients who come to counseling sessions or stay in halfway houses or therapeutic communities and never engage in the treatment process may be told that there is nothing more that the treatment program can do for them at this time.

Many individuals make an initial appointment at a treatment program to satisfy others but are not seeking long-term services. Following the assessment interview, they may thank the interviewer, saying they now understand the problem and are sure they can quit or control alcohol or other drug use on their own. Sometimes a brief intervention can help problem drinkers reduce their drinking (see  chapter 6 ). But many individuals have substance use disorders that are more serious than a brief intervention can address. Even so, unless the individual is in an immediate life-threatening situation, treatment providers cannot force someone to receive services. Some professionals object to the idea that a client would be pressured or coerced at all. Treatment providers generally consider their services voluntary, even if a client is under a civil court order or a parole or probation officer requires them to attend.

If an individual appears to have an alcohol or drug problem but resists treatment, the assessment specialist may encourage him or her to attend an educational program, a few individual or group counseling sessions, or some meetings of a mutual- help group before rejecting the notion of treatment entirely. If none of these alternatives is accepted, the professional should be supportive of the individual for his or her willingness to come in at all, being sure to leave the door open should he or she want to return later. Sometimes individuals are willing to make an agreement with the assessment specialist—if they are unable to stay clean or sober, use more than specified amounts of alcohol or drugs during a given time period, or encounter negative consequences of alcohol or drug use, they will concede that they cannot control their use, and they agree to re-contact the assessment specialist for treatment. This approach sometimes works in helping individuals identify alcohol and drug problems, especially those who are certain that they can control their use. Some chemical dependency specialists may use more direct approaches, depending on the client and the situation, but there is a growing interest today in less confrontational and more supportive approaches, such as those described in  Box 5.1  called The Motivation to Change.

Finally, it may be useful to remember that labeling a client unmotivated or resistant to treatment may be unfair or unwarranted. There is a great deal experts do not know about how to treat substance use disorders. Some individuals are able to maintain sobriety or stay “clean” only after dozens of detox admissions. Others try hard but never achieve long periods of clean and sober time. The types of approaches available to treat substance abuse and dependence are relatively limited. Professionals rely heavily on cognitive-and behavior-based strategies, though there is increasing evidence of a genetic component to chemical dependence. There may be many types of alcoholism and drug addiction, each with its own complex etiology. In sum, clinicians do not yet have the tools to treat all individuals successfully, and this, rather than lack of client motivation, may be at the heart of why so many struggle with recovery.

Ethics of Chemical Dependency Treatment

Ethical dilemmas arise each day in the chemical dependency field that warrant professionals’ careful attention (see  Taleff, 2010 ). The professional organizations and licensing and certification bodies that represent social workers, psychologists, chemical dependency counselors, and other human service professionals generally have codes of ethics to which members are expected to subscribe. For example, the code of ethics of NAADAC, the Association for Addiction Professionals (2011), covers areas such as the counseling relationship, confidentiality, cultural diversity, supervision and consultation, and policy and political involvement. According to this code, NAADAC members should provide clients “only that level and length of care that is necessary and acceptable.” Members governed by the code are encouraged to be proactive in seeing that individuals and groups of all ethnic and social backgrounds have access to treatment. The code also addresses factors such as culture or disability that require consideration in working with clients. Members of other human service professions are bound by similar codes of ethics.

BOX 5.1 The Motivation to Change

Most people want to change something about themselves. They might want to study harder, spend more time with loved ones, lose weight, exercise more, reduce drinking, or stop smoking or using other drugs. Many won’t make substantial changes in these areas. They may think about it or they may try, while others will be only marginally aware that a problem even exists.

What makes people change is an important question in psychotherapeutic treatment. When it comes to alcohol and other drug problems, some people think that a serious crisis must occur before a person develops sufficient motivation to change. Others contend that professionals can intervene before a client “hits bottom” and help motivate him or her to change.

Stages of Change

Prochaska, DiClemente, and Norcross (1992)  have devoted a great deal of study to the process of change—the type that is made on one’s own and the type that takes place in the psychotherapeutic process. They believe that a series of stages typifies the change process in both types of situations, regardless of the behavior the individual wishes to change (also see  Prochaska & DiClemente, 1982 ). Much of their initial research was done with smokers. Considerable research on the model has also been conducted with people who have alcohol and other drug problems (see, for example,  Connors, Donovan, & DiClemente, 2001 ). They call their model transtheoretical because they believe it is compatible with a wide range of treatments. The five stages of change they identified are:

1. Precontemplation, in “which there is no intention to change in the foreseeable future” and people may be “unaware or underaware of their problems.”

2. Contemplation, “in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action” (in this stage, the pros and cons of the problem and solution are weighed).

3. Preparation, in which individuals intend “to take action in the next month.”

4. Action, in which individuals have successfully modified their situation “from one day to six months.”

5. Maintenance, in which people continue to change and prevent relapse. ( Prochaska et al., 1992 , pp. 1103–1104)

Prochaska and colleagues note that change is generally not a linear progression through these five stages but often involves reverting to an earlier stage before additional progress is made. Although some people may remain stuck at the first or second stage, the researchers note that individuals usually learn something at each point and generally do not regress completely. The techniques that will be successful with clients depend on the stage at which they are.

Just how does one move from one stage to the next, and how can treatment providers facilitate this process?  Table 5.2  indicates the processes that seem to facilitate movement between stages.

Motivation, Not Confrontation

Miller and Rollnick (1991 ,  2002 ;  Miller, 1999 ) also address the process of change in their work on motivational interviewing: Motivational interviewing is a particular way to help people recognize and do something about their present or potential problems. It is particularly useful with people who are reluctant to change and ambivalent about changing. It is intended to help resolve ambivalence and to get a person moving along the path to change. ( Miller & Rollnick, 1991 , p. 52)

TABLE 5.2 The Right Change Process at the Right Time: What Helps Clients Move from Here to There?

Stage of change
Precontemplation to contemplation	Contemplation to preparation	Preparation to action	Action to maintenance	Staying in maintenance
Most relevant change processes
Consciousness raising Dramatic relief Self-reevaluation Environmental reevaluation	Self-reevaluation Environmental reevaluation Social liberation	Self-liberation Stimulus control Counter-conditioning Helping relationships	Self-liberation Stimulus control Counter-conditioning Helping relationships Reinforcement management Helping relationships	Self-liberation Stimulus control Counter-conditioning Helping relationships Reinforcement management Social liberation
Experiential Processes · Consciousness raising: Individual gains knowledge about him/herself and his/her behavior through discussion, reading, etc. · Dramatic relief: Individual experiences and expresses feelings about the problem and solutions through grieving losses, role playing, etc., or may have a significant emotional experience related to the problem. · Self-reevaluation: Individual recognizes how a current behavior conflicts with his/her goals and values(values clarification). · Environmental reevaluation: Individual recognizes effects his/her behavior has on others and his/her environment through empathy training, other processes. · Self-liberation: Individual decides to make commitment to change often with specific goals; may share decision with others and ask for their support.
Behavioral Processes · Stimulus control: Individual avoids or counters stimuli (“triggers”) that elicit problem behavior through restructuring environment (e.g., avoiding bars), avoiding high risk cues (e.g., arguments), etc. · Counter-conditioning: Individual substitutes healthy behaviors for problem behavior using relaxation, desensitization, assertion, positive self-statements, etc. · Helping relationships: Individual utilizes therapeutic alliance (open, trusting relationship), social support, mutual-help groups to discuss/address problem. · Reinforcement management: Individual rewards self or is rewarded (directly or indirectly) by others for making changes. · Social liberation: Individual works for changes in society through policies/political action, advocating for rights of oppressed, empowerment.

Sources: Based on tables in “In Search of How People Change” by James Prochalska from American Psychologist, vol. 7, # 9, Sept 1992 and from Mary Marden Velasquez et al., Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual, Table, 1.1., p. 10. Guilford Press (2001). Used by permission.

Miller and Rollnick stress the importance of the therapist’s role in the treatment process, saying that therapists have widely varying success rates with clients. They advocate the use of non-possessive warmth, genuineness, and particularly  accurate empathy (reflective listening, rather than identification with the client, as described by noted psychotherapist Carl  Rogers [1959] ), and they see accurate empathy as much more productive than confrontation. Miller and Rollnick also consider reasons that alcohol and drug treatment providers have used confrontation. For example, myths developed that alcoholics and drug abusers were especially defensive and that leaders in the field of addiction treatment advocated confrontation to break down those defenses. Miller and Rollnick call both these ideas erroneous. Denial, they contend, is not more characteristic of alcoholics than of others; it is a normative reaction in the face of strong confrontation. In addition, neither Vernon  Johnson (1973) , who developed the technique called “The Intervention” (see  Chapter 10  of this text), nor the Minnesota Model nor Alcoholics Anonymous (see  Chapter 6 ) advocate heavy, aggressive confrontation. Education of helping professionals generally does not include aggressive or authoritarian confrontation.  Table 5.3  describes the “spirit” of motivational interviewing and contrasts it with an opposite approach to counseling, and  Table 5.4  describes the four general principles of motivational interviewing.

TABLE 5.3 The Spirit of Motivational Interviewing

Fundamental Approach of Motivational Interviewing	Mirror Image Opposite Approach to Counseling
Collaboration. Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change.	Confrontation. Counseling involves overriding the client’s impaired perspectives by imposing awareness and acceptance of “reality” that the client cannot see or will not admit.
Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values.	Education. The client is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment.
Autonomy. The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice.	Authority. The counselor tells the client what he or she must do.

Source: From MOTIVATIONAL INTERVIEWING, 2/e, by William R. Miller and Stephen Rollnick. Used by permission of Guilford Press.

Change and a Systems Approach

The models we have reviewed rely primarily on individual factors to promote change. Using a social work perspective,  Barber (1995)  recommends a holistic or systems model to address addictions because it better captures “the role of supply-side and demand-side drug prevention policies (mesosystem) or the (sub)cultural (exosystem) factors surrounding the overuse of certain drugs. If only because drug use is not randomly distributed within society, sociocultural factors, such as socioeconomic deprivation, norms, and anomie, must have explanatory and predictive utility” (p. 44) in our work with people who experience alcohol and drug problems.

Barber believes that his model focuses more on what can be done to promote change among precontemplators, such as the use of environmental strategies. Thus, the text you are reading considers not only pharmacological interventions and psychosocial interventions with individuals, families, and groups, but it also considers cultural perspectives (see  Chapters 11  and 12), prevention strategies (see  Chapter 7 ), and policy approaches (see  Chapter 8 ) that might affect alcohol and other drug problems.

TABLE 5.4 Principles of Motivational Interviewing

Principle 1. Express empathy: · Acceptance facilitates change. · Skillful reflective listening is fundamental. · Ambivalence is normal.

Principle 2. Develop discrepancy: · The client rather than the counselor presents the arguments for change. · Change is motivated by a perceived discrepancy between present behavior and important goals or values.

Principle 3. Roll with resistance: · Avoid arguing for change. · Resistance is not directly opposed. · New perspectives are invited but not opposed. · The client is a primary resource in finding answers and solutions. · Resistance is a signal to respond differently.

Principle 4. Support self-efficacy: · A person’s belief in the possibility of change is an important motivator. · The client, not the counselor, is responsible for choosing and carrying out change. · The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy.

Source: From MOTIVATIONAL INTERVIEWING, 2/e, by William R. Miller and Stephen Rollnick. Used by permission of Guilford Press.

Human service professionals are expected to represent their credentials fairly, to treat clients only within their areas of expertise, and to make referrals when needed. Licensing and certification boards generally require that members participate in continuing education in order to keep their knowledge and skills current.

Perhaps the most frequent complaint filed with licensure and certification boards is that professionals have violated professional ethics by engaging in sexual relationships with current or former clients. Professionals should also not provide services to individuals with whom they have had prior sexual relationships. There are also taboos against other dual relationships with clients, such as not engaging with them in business ventures and other activities for profit.

Another issue that arises in the human service professions (and that has special import in the fields of chemical dependency and mental illness) is that of impaired professionals ( Bissell & Royce, 1994 ) since a substantial number of chemical dependency professionals are themselves in recovery. Codes of ethics require that professionals address their own problems when these issues might prove to be detrimental to clients. Some professional organizations have peer-assistance programs that help professionals obtain treatment for such problems. When a professional does not take steps to rectify his or her own problems, colleagues who are aware of these problems may be obligated to report them to the appropriate licensing or certification authority. For professionals who are also in recovery, another issue is whether or how much information to disclose to clients about their own status as a recovering individual. Some professionals refrain from revealing this personal information. There is no absolute way to handle such disclosure, and the professional may address it on a case-by-case basis, especially if clients ask about it directly.

Respect for client confidences is an important aspect of the codes of ethics of human service professionals. Professionals working in alcohol and drug programs should be aware of the portion of the Federal Register called “Confidentiality of Alcohol and Drug Abuse Patient Records” (42 CFR, Part 2) as well as the Health Insurance Portability and Accountability Act (HIPAA). Generally 42CFR is more restrictive than HIPAA and was intended to provide strong protections for client confidentiality in order to encourage people to seek treatment (see  Brooks, 2004 , for information on legal aspects of confidentiality). Chemical dependency professionals need to know this information to protect their clients and themselves. We describe some of its major points and discuss other issues relevant to confidentiality. These comments are no substitute for good legal counsel and are meant only to suggest some of the issues in the field.

Without an individual’s written permission, treatment providers are usually prohibited from revealing whether or not the person is a patient or client in a chemical dependency treatment facility or any other information about the individual or his or her treatment. Providing information to those outside the treatment program and requesting information from other sources generally require the client’s written permission. A client’s written authorization to release information must state the name of the agency, program, or individual requesting the information; the agency, program, or individual from which the information is requested; the type of information that the client wishes to be provided; the purpose for which the information will be used; the date the release is signed and the date on which the release expires; and the client’s signature and a witness’s signature as proof of permission.

As noted earlier, staff may wish to obtain certain types of information, such as medical or psychological information, that may help them better serve the client. A consent or release-of-information form is also required for the staff to communicate with the client’s spouse or other loved ones, since it should not be assumed that these individuals know that the client is receiving treatment or that the client wants the staff to communicate with them. Professional conduct also suggests that information about the client not be shared or discussed with other staff in the facility, unless they have a need to know this information to serve the client or in cases where a consultation is needed. Clients should be informed of the extent to which staff may need to share information with each other.

Sometimes a client requests that the treatment program give information to others. For example, a client may want his employer to know that he is attending treatment, or a client may be anxious for her probation officer to hear that she is making progress in treatment.

Exceptions to the right to confidentiality should be explained to the client. For example, under certain circumstances, treatment records of alcohol and drug abuse patients may be subject to subpoenas or court orders. Attempts may be made to subpoena records in cases where there are criminal charges against the client, in child custody cases, and under other circumstances. The issue of what to record in clients’ charts or files is an important one. Many helping professionals do not enjoy privileged communication with their clients; that is, they may be ordered by the courts to provide information even about matters not contained in the client’s case record. When a professional thinks that releasing information would not be appropriate, he or she should be given an opportunity to explain that to the court so that the court can decide the matter.

In a medical emergency, information necessary to save the client’s life may be released. If the individual may be harmful to himself or herself, such as in the case of a client with a plan to commit suicide, the professional usually has a responsibility to seek protection for the client through an appropriate mental health referral. Sometimes this involves asking the local mental health crisis team or law enforcement agency that handles these problems to intervene. If a client threatens serious harm to another, there may be a “duty to warn” and the professional may be liable for injury sustained if appropriate steps are not taken. Child abuse and neglect must be reported according to state statutes. State laws may also require reporting of elder abuse and other crimes. Knowledge of state and federal law is thus necessary in the chemical dependency field.

Chemical dependency researchers may be afforded special confidentiality protections by obtaining a certificate of confidentiality from a federal agency such as NIAAA or NIDA. The certificate covers information obtained for research (not treatment) purposes only, but it does not provide an exemption from reporting child abuse and neglect. The certificate is particularly useful when subjects are asked about substance use or illegal activity (e.g., illicit drug use or crimes committed); since it is designed to protect researchers from having to release such information in any type of court (administrative, civil, criminal, etc.). The research must be legitimate, but the federal government or other external source does not have to fund the research for it to qualify for a certificate of confidentiality.

Legal issues arise more frequently than ever in the chemical dependency field, as they do in most fields, yet the appropriate responses are not always clear. Questions about what procedures to follow if law enforcement officers arrive at the door with an arrest warrant for a client or a subpoena for a file are not unusual. Good legal counsel is important—so is education about legal matters, since staff may be pressed to respond quickly.

Legal obligations are not always synonymous with ethical obligations. For example, a state may not have a legal “duty to warn,” but a professional may feel morally obligated to do so. The highest calling may be to one’s own ethical standards, but that may result in legal repercussions, such as being held in contempt of court for not releasing information if there is a proper court order to do so.

Referrals

Human service professionals of all types and in virtually all settings encounter individuals with substance use disorders and their loved ones. From elementary and secondary schools to the child welfare agency to the workplace to the nursing home, substance use disorders appear. Although social workers, psychologists, and other human service professionals should be prepared to screen for these problems, they may not be qualified to diagnose and treat them. When this is the case, a referral for further assessment or services is indicated. Some agencies—for example, family service agencies—may be able to provide these services in house. In other cases, knowing the local alcohol and drug abuse treatment agencies, their purposes, and their staff members can facilitate a referral. For example, a child protective services worker suspects that a child neglect case is due to alcohol abuse, but he needs a confirmatory diagnosis to help the mother get treatment so that she can retain custody of her children. Knowing the woman’s limited financial resources, he refers her to a community mental health center with a substance abuse treatment component. An adult protective services worker contacts an inpatient chemical dependency treatment to assist with a client whose dependence on alcohol and benzodiazepines is preventing her from living independently. Or a parole officer makes sure a bed in a therapeutic community for offenders with chemical dependency problems will be available before a parolee who is addicted to heroin is released from prison.

Chemical dependency professionals not only accept referrals, they also make referrals to other agencies. As indicated in the discussion of assessment, clients with alcohol or other drug dependence often need additional services, such as vocational guidance, parent education, medical care, public assistance, and legal assistance. Keeping abreast of the services available in the community and developing cooperative working relationships with those who provide them are important professional responsibilities. Some agencies, such as the local offices of the state vocational rehabilitation agency, may designate a particular counselor or counselors to work with clients who have alcohol or other drug problems, or counselors may have general caseloads that include clients with substance use disorders. Informal knowledge of staff of other agencies that are most favorably disposed to working with clients who have substance use disorders can be a big help, and it usually does not take long to learn who these individuals are.

Making a referral on which the client follows through can involve more than writing a name and a phone number on a piece of paper. No one wants to act as an enabler (in the negative sense of the word) or increase a client’s dependency. However, informing the client of the referral’s purpose and what the referral source may or may not be able to do, calling ahead for a client, and letting the client know specifically for whom to ask can be helpful. Clients who have mental or physical disabilities in addition to alcohol and drug problems may need extra support or assistance. This may mean providing transportation, accompanying them to the referral agency, or helping them complete application forms and compile necessary information. Clients who are desocialized or particularly unassertive may also benefit from someone to accompany them until they can develop the skills to negotiate these situations themselves.

Additional obstacles, such as lack of child care and language barriers, may also need to be addressed before a client can take advantage of referrals. In making referrals for health care, it is particularly helpful to know if the client has traditional private health insurance; belongs to a health maintenance organization (HMO) or other managed-care program; receives Medicaid or Medicare; has another type of coverage; or is entitled to services from the U.S. Department of Veterans Affairs.

Many professionals also refer clients to mutual-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) (see  Chapter 6 ), but making these referrals is different. These groups do not have a staff of professional human service workers, and arrangements for clients generally cannot be made in advance. Anonymity of mutual-help group members is stressed, so there is no list of members’ names and telephone numbers. The professional can give the client a list of meeting times or a website address or encourage the client to call the group for information. Some mutual-help groups have telephone lines that are staffed 24 hours a day; others have 24-hour answering services. Some have limited hours when telephones are staffed, and they may use a recording to give callers information or allow them to leave messages at other times.

Providing a list of meetings is not necessarily an effective way of encouraging clients to visit mutual-help groups. Many individuals do get to their first meetings on their own, but clients are frequently hesitant to go to a group about which they know very little. Professionals can make the process considerably easier. One way is to educate clients about what to expect in advance.

Some professionals “wear two hats”—they are human service professionals and they are members of mutual-help groups. Initially, they might accompany clients to a meeting or two (perhaps a meeting they usually do not attend) and explain what “working” a mutual-help program is about. Professionals who are not members of these groups may assist by accompanying the client to an open meeting, where those who are not “alcoholics” or “addicts” are welcome.

Many communities have a number of mutual-help groups. Even professionals who are recovering from alcohol or drug problems do not attend all the groups in their community. Some groups are only for men or only for women, some are for Spanish speakers, some are for nurses and doctors, and some are for gay men or lesbians. It is not possible for someone who wears two hats to fit in all the groups that his or her clients might need. Neither is it healthy for counselors to fill all these roles for clients. It may blur the professional-personal boundary in ways that raise ethical concerns. Professionals also do not have time to fill this function for all their clients, and clients can benefit from widening the circle of recovering individuals they know. “Twelve-step work” refers to the desire of AA and NA members to take the message of these programs to others. It may be more effective for professionals to maintain contact with recovering individuals in the community who wish to assist newcomers to the many mutual-help groups that have emerged for individuals who have alcohol and drug problems. Clients may be more likely to follow through on a referral when arrangements have been made for someone to accompany them to a meeting or they have been in contact with a member.

There are also mutual-help groups for loved ones (spouses, partners, children, and other family members and friends), such as Al-Anon and Naranon. Similar procedures can be used to make referrals to these groups. Mutual-help groups regard themselves as strictly voluntary programs. Many do allow the secretary of the group to sign slips of paper so that attendees can verify their presence at the meeting if the courts or probation or parole officers require this

CHEMICAL DEP.

Chapter 6 Treatment: The System of Care

This chapter describes the system of care for those with alcohol or drug problems. Following diagnosis and assessment, the next step is to help clients select the types of treatment and other services that will meet their needs as closely as possible. The phrase matching clients to treatment has been used to describe this part of the helping process. It requires knowledge about all components of the system of care available to those with substance abuse or dependence, as well as mutual- or self-help programs. Professionals want to provide clients with the most optimal treatments and services, but many limitations can prevent this from happening. Particular services may not be available in a given locale. Clients may not have the financial resources to obtain services. Clients and the professionals they encounter may not be aware of resources. Clients may get whatever is available without sufficient regard for their particular needs and circumstances. Client preferences also play a role in selecting treatment modality. This chapter presents treatment options and discusses the treatment outcome evaluation literature—just how successful is treatment for substance use disorders?

Components of the Treatment System

We conceptualize approaches for treating chemical abuse and dependence using a continuum of care comprised of nine major components that are most commonly offered to clients: (1) detoxification, (2) intensive treatment, (3) residential programs, (4) outpatient services, (5) medication, (6) aftercare, (7) maintenance, (8) education and psychoeducation, and (9) adjunctive services. Some individuals may utilize each of these services over time, whereas others need only particular components. The continuum represents a comprehensive or ideal service delivery system designed to meet the range of clients’ biopsychosocial needs. We also discuss some less traditional methods of treatment for those who have alcohol or drug problems.

Detoxification

Detoxification is often the first and usually the briefest step in the recovery process. Individuals often need these services if they have a physical dependence on alcohol or other drugs that results in withdrawal symptoms when drug use is reduced or terminated. Those with very mild symptoms may not require medical attention, and many of these individuals withdraw on their own. Others use drugs like hallucinogens that usually do not produce a physical dependence ( Drug Enforcement Administration, 2004 ), although serious reactions such as psychosis require intervention. For those who need assistance with detoxification, the type of drugs on which they are dependent, the severity of their symptoms, and their medical, psychological, and social situations will help determine whether detoxification is done on an inpatient basis in a hospital, in another inpatient setting, or on an outpatient basis.

Medical, Hospital Detoxification

Medical, hospital detoxification takes place in a general hospital or in a hospital or hospital unit specifically designed for chemical dependency treatment. In some cases, an individual’s private physician will direct them to a hospital for admission for detoxification. Other times, those dependent on alcohol or other drugs have medical emergencies such as acute withdrawal symptoms, overdoses, or accidents related to alcohol or drug use that cause them to use hospital emergency departments. In emergencies, hospitals must usually treat individuals, whether or not they have the means to pay for their care. The presence of medical and social service staff knowledgeable about alcohol and drug problems increases the likelihood that patients will be referred to treatment programs or other services for chemical dependency following detoxification or other emergency treatment.

Hospitals with chemical dependency treatment units and specialty hospitals devoted to chemical dependency treatment may also provide detoxification services. Immediately following detoxification, clients can begin intensive inpatient or outpatient chemical dependency treatment at these facilities (or other appropriate specialty programs). State psychiatric hospitals that treat individuals with serious mental illness and other psychiatric hospitals may also offer addiction treatment services, and some include detoxification services.

Medical, Nonhospital Detoxification

Detoxification is also conducted in inpatient community-based detoxification centers, sometimes referred to as medical, nonhospital (or social setting) detoxification. The staff includes physicians, nurses, and other professionals who provide psychosocial services to patients. These detoxification facilities sprang up around the country following passage of the federal Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (also known as the Hughes Act, after its primary sponsor, Senator Harold Hughes). They were intended to stop the revolving door for those whose lives consisted of cycles of drinking, arrests for public intoxication, and short jail terms. These facilities may focus on treating alcohol withdrawal or assist with withdrawal from other types of drugs as well.

Patients in community detoxification centers may be self-referred, brought by a relative or friend, or referred by community gatekeepers such as the police, probation or parole officers, health department staff, the clergy, or social agency personnel (see  Box 6.1 ). Some centers require that a physician screen patients before they are admitted to prevent inappropriate admissions. For example, some individuals may be experiencing a psychiatric emergency requiring care in a psychiatric hospital or a medical crisis that requires treatment in a general hospital. Some community “detox” centers permit nurses to admit patients and provide most of the medical care. There are “standing orders” that provide instructions for the care of patients with varying degrees of withdrawal symptoms. Each day a physician examines patients and provides any special instructions needed. The physician is also on call for emergencies. There are some limitations to the assistance that community detoxification centers can provide. For instance, if patients do not arrive at the detoxification center early enough to receive medical attention that will prevent the most serious withdrawal symptoms, such as seizures or delirium tremens (DTs), they may have to be transferred to a hospital.

Since the primary concern of community detoxification programs is chemical dependency treatment, more is usually done to link the client to additional services needed for recovery than in general hospitals, where the staff may be overwhelmed with medical emergencies or is not as well versed in serving patients with alcohol or drug problems. While at the detoxification program, patients are often provided alcohol and drug education and receive initial counseling and referral services. They are usually expected to participate in educational group sessions as soon as they are physically able. Loved ones may also be briefly counseled about the need for additional services for themselves as well as the patient.

Patients served in community detoxification programs often have limited financial resources. They may be charged on a sliding scale, based on their ability to pay, though recent federal legislation would give more Americans access to health insurance. The number of beds in a center usually varies with the size of the city or community served. Rural areas may have no community detox center, and those needing services may have to travel long distances to obtain care ( Lenardson, Race, & Gale, 2009 ).

Whether detoxification occurs in a hospital or in a community program, medical personnel observe the patient and assess the severity of withdrawal symptoms to determine the medical regimen needed. Often, the medical personnel do not know what substances the patient has ingested, how much has been ingested, and over what period of time. They may be unaware of the withdrawal symptoms the patient has experienced in the past. Therefore, they must proceed cautiously before administering medications for withdrawal (such as benzodiazepines for alcohol withdrawal [ Myrick & Wright, 2008 ] or methadone or buprenorphine for heroin withdrawal [see  National Institute on Drug Abuse, 2008 ;  Polydorou & Kleber, 2008 ]). Treatment—including the type and amount of medication, if any, to be administered—will depend on whether the patient’s withdrawal symptoms are mild, moderate, or severe. Patients often ask for or demand additional medication to further mitigate physical and psychological discomfort.  Kasser and colleagues (1998)  emphasize that “every means possible should be used to ameliorate the patient’s withdrawal signs and symptoms” (p. 424). When medical staff feel that additional medication is not warranted, they generally respond with verbal encouragement and support that the symptoms will pass, but sometimes a patient attempts to bring alcohol or drugs to the facility or have someone bring alcohol or drugs to them.

BOX 6.1 A Community Detoxification Center Patient

Ed Welch, *  a white male in his late forties, was well known at the community detox center. He had been admitted about six times in the last year as a result of his dependence on alcohol. Ed’s most prominent withdrawal symptom was severe tremors. His medical history also included several bouts of gastritis. The medical staff was always able to manage Ed’s care without referral to the hospital, and it was amazing how much better he looked after a five-day stay. Ed was a cooperative and quiet patient. He worked as a welder and his boss would bring him in when he got drunk. As soon as he was sober, Ed’s boss would put him back to work. Ed was divorced, never saw his grown children, and didn’t seem to have any friends. He had no trouble downing two fifths of whiskey when he went on a binge. The detox staff was never able to get Ed to enter the halfway house or to attend outpatient groups. It seemed that the thing Ed liked least was talking. He came to AA sometimes but never said much. Ed did get an AA sponsor, a member with a history a lot like Ed’s. Ed often managed to put a few months of sobriety together, but his binges, although less frequent, continued, and he returned to the detox center intermittently.

* The clients described in this chapter are fictitious or represent composite cases.

The stay in detoxification programs is generally brief but depends on the drugs on which the patient is dependent. For example, the acute problems associated with alcohol withdrawal are likely to pass in a few days, whereas the period for barbiturate withdrawal is longer. Withdrawal from sedative-hypnotic drugs presents particular dangers due to the possibility of seizures or DTs. Withdrawal from more than one drug further complicates matters. Patients are detoxified from each drug sequentially, beginning with the drug that produces the most serious withdrawal symptoms ( Center for Substance Abuse Treatment, 2006 ).

Since there is usually a high demand for the beds in community detoxification programs, patients may be referred to an inpatient or outpatient treatment program, a halfway house, the Salvation Army, or a mission as soon as withdrawal dangers have passed. Some patients are reluctant to leave, especially those who are homeless. For them, the detox center is a safe shelter and a temporary home. Others do not wish to be treated in the detoxification center at all and may leave or try to leave prematurely. Although some patients are referred by the courts or are under pressure from other authorities (e.g., probation department or child welfare agency) to enter the center, patients are generally considered to be there voluntarily. Voluntary patients cannot be required to stay, but local law enforcement may be called if a patient considered dangerous to himself or herself or to others attempts to leave. Some patients are mandated to treatment involuntarily under civil procedures. Should these patients “elope” or otherwise leave against medical advice or without permission, staff may be required to notify the appropriate authorities.

Outpatient Detoxification

When withdrawal can be medically managed without the need for inpatient treatment, outpatient (ambulatory) care may be an economical alternative ( Mee-Lee, Shulman, Fishman, Gastfriend, & Griffiths, 2001 ;  Rawlani, Vekaria, & Eisenberg, 2009 ). The use of outpatient detoxification is also contingent on the patient’s social and psychological states. Suicidal or severely depressed patients are obviously not good risks for outpatient detoxification, and outpatient detoxification is not a viable option if the patient lacks the ability or supervision to comply with the treatment protocol. Whether the patient has housing and emotional supports should also be considered. Various resources provide guidelines for making referrals for outpatient detoxification (see  Center for Substance Abuse Treatment, 2006 ; Mee-Lee et al.). Outpatient detoxification may be accomplished through chemical dependency treatment programs or physicians’ offices.

Effectiveness of Detoxification Services

From a purely medical standpoint, detoxification can be successfully accomplished on an inpatient basis in a hospital and often in other inpatient settings, or on an outpatient basis in appropriate circumstances. Community detoxification centers have been highly successful in helping patients detoxify safely, and their costs are substantially less than hospital care. Although there are advantages of inpatient detoxification, such as continual medical supervision,  Hayashida and colleagues (1989)  found that patients requesting detoxification for mild to moderate alcohol withdrawal syndrome can be successfully detoxified on an outpatient basis if they are screened to ensure that they do not have complicating medical and psychiatric problems. These findings are particularly interesting, given the low socioeconomic status of the patients who participated in the study and their lack of social supports, including some with unstable living arrangements. Others emphasize that “out-patient detoxification for homeless and severely drug- and alcohol-dependent populations is unrealistic. For this group, access to residential detoxification is vital as it provides an environment where potentially serious medical and psychological complications can be managed” ( Silins, Sannibale, Larney, Wodak, & Mattick, 2008 ). Empirical evidence to determine when outpatient detoxification can be successfully used is lacking ( Day, Ison, & Strang, 2010 ).

In addition to the procedures that have traditionally been used to help patients withdraw from alcohol or other drugs, rapid and ultra-rapid detoxification for opiate withdrawal is also being used. These procedures may have appeal for patients because they are intended to reduce the lengthy and uncomfortable withdrawal period from opiates. Ultra-rapid detoxification is usually conducted in a hospital, where the patient receives general anesthesia or heavy sedation in addition to medications for withdrawal. These procedures are costly, and thus available only to those with the means to pay for them. They are controversial because of safety concerns and lack of evidence to support their use ( American Society of Addiction Medicine, 2005 ;  Collins, Kleber, Whittington, & Heitler, 2005 ;  Gowing, Ali, & White, 2010 ).

Medically safe withdrawal is the immediate goal of detoxification programs. Of importance in the long run is whether participation in a detoxification program promotes patients’ further use of treatment and rehabilitation services. There is widespread agreement in the field that “medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse” ( National Institute on Drug Abuse [NIDA], 2009a , p. 4; also see  Center for Substance Abuse Treatment, 2006 , and see  Box 6.2 ). Often, disappointingly small numbers of alcoholics and addicts continue in treatment following detoxification ( Haley, Dugosh, & Lynch, 2011 ).

Intensive Treatment

Intensive treatment was once synonymous with inpatient care, but it is now frequently offered on an outpatient basis.

Intensive Inpatient Care

Intensive inpatient treatment programs originated primarily to assist people with alcohol use disorders but now include those with other drug problems. These programs typically lasted for 28 or 30 days, the maximum period that many health insurers would pay for this care, though some programs were longer. In recent years, managed health care has had a major impact on intensive inpatient treatment, with insurers often limiting inpatient stays (also see  Chapter 16 ). Among the best-known intensive treatment programs is the Betty Ford Center. It is often those who have the financial resources and can be absent from work or family responsibilities who are able to avail themselves of inpatient care. Intensive inpatient treatment may be the logical choice when an individual is unlikely to remain alcohol or drug free in his or her current environment.

Intensive inpatient chemical dependency treatment programs may be located in a special unit of a general hospital or offered by a specialty hospital or other inpatient facility devoted to psychiatric or chemical dependency treatment. Some intensive inpatient treatment facilities are privately owned and intended to earn profit; others are private, not-for-profit or public facilities. The number of these programs increased tremendously during the 1970s and 1980s, along with wider recognition that chemical dependency can be successfully treated and as insurers succumbed to pressure to cover treatment. Since inpatient care is quite expensive (a stay in a private inpatient treatment program can cost as much as tens of thousands of dollars), managed health care and other cost constraints have taken their toll, resulting in the closing of many of these inpatient programs ( Roman, Johnson, & Blum, 2000 ).

Clients who have insurance or other resources can usually get immediate admission to for-profit intensive inpatient programs, but not-for-profit and public programs often have waiting lists. Maintaining sobriety while awaiting admission to a public or not-for-profit program can be a challenge for clients. A basic tenet of addiction treatment is that it should be readily available to those who need it ( NIDA, 2009a ). With changes in federal laws governing health insurance parity for alcohol and drug treatment and greater access to health insurance for Americans, there is hope that more people will be able to avail themselves of alcohol and drug treatment.

Although the treatment services in inpatient programs vary to some degree, many are similar to what is called the Minnesota model, which has been described as “an abstinence oriented, comprehensive, multi-professional approach to the treatment of the addictions, based upon the principles of Alcoholics Anonymous” ( Cook, 1988a , p. 625; also see  McKay & Hiller-Sturmöhfel, 2011 ;  Owen, 2000 ). The model originated at the Willmar State Hospital in Minnesota in the late 1940s and was adopted for use in other settings, such as the Hazelden rehabilitation center in Center City, Minnesota (see  White, 1998 ).

BOX 6.2 Principles of Effective Drug Addiction Treatment

1. Addiction is a complex but treatable disease that affects brain function and behavior.

2. No single treatment is appropriate for everyone.

3. Treatment needs to be readily available.

4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

5. Remaining in treatment for an adequate period of time is critical.

6. Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment.

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.

9. Many drug-addicted individuals also have other mental disorders.

10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.

11. Treatment does not need to be voluntary to be effective.

12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

13. Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

Source:  National Institute on Drug Abuse. (2009, April) . Principles of drug addiction treatment: A research-based guide, 2nd ed. Bethesda, MD: U.S. Department of Health and Human Services.

The services these programs most commonly provide are education about chemical dependency, group and individual counseling or therapy, and an introduction to mutual-help programs. Other services promote general health and well-being. Examples are learning to reduce stress, improving communication skills and other social skills, lectures or consultation on adopting good nutritional habits and other healthy routines, and social and recreational alternatives to drug use. There are, of course, limits on what can be accomplished in a few weeks. Many clients are just coming to grips with their chemical dependency problem. In this early stage of recovery, only so much information can be processed and retained, especially by those with long-term dependency who are newly detoxified. A criticism of the traditional Minnesota model is that services are “bundled”; that is, every client receives the same regimen of services, regardless of his or her individual needs ( Miller, 1998 ; also see  Mee-Lee et al., 2001 ).

Intensive inpatient programs vary in the methods used to involve clients’ significant others. Education is one means, beginning with basic information on alcohol and drugs and what constitutes “addiction” or “dependence.” Topics such as chemical dependency as a family disease and codependency generally receive attention (see  Chapter 10 ). Loved ones may also be introduced to mutual-help groups such as Al-Anon and Naranon. Therapy sessions may be scheduled for individual families, or families may meet in groups. Some family groups are just for spouses and other adult partners; others include children, parents, and others important in the client’s life. Though it is relatively rare, in some programs, family members, particularly spouses and other adult partners, spend a week or so in residence at the program.

Intensive Outpatient Care

Reliance on intensive inpatient treatment for chemically dependent individuals has been questioned with regard to costs and effectiveness. Professionals often directed chemically dependent individuals to inpatient treatment because they assumed it was the best alternative or because of the lack of other treatment alternatives. In the early years of insurance coverage for substance use disorders, insurers often limited coverage to inpatient care. Patients were told that inpatient treatment came first, regardless of their personal circumstances. But insistence on inpatient treatment may have alienated potential clients concerned about disruption to their work and family lives. Single parents, those with limited financial resources, and those concerned about explaining a long job absence may see outpatient care as their only viable treatment option. Intensive outpatient treatment is now the preferred service for those who can continue to function at home and in the community.

The services provided in intensive outpatient treatment are the same as those provided during inpatient treatment, but clients work at their regular jobs or care for their families during the day and usually attend treatment in the evenings or on weekends. A typical program for clients with alcohol use disorders may involve participation four evenings a week over a 10- to 12-week period.

The Matrix Model is a longer-term intensive outpatient treatment approach developed to treat those who abuse stimulant drugs ( Huber et al., 1997 ;  National Institute on Drug Abuse, 2009a  &  b ;  Rawson et al., 1995 ). A focus of the model is the client’s development of a positive relationship with a master’s-level therapist, who provides individual counseling and serves as the client’s “primary treatment agent.” Multiple treatment modalities are used. The first phase of treatment, which lasts six months, includes individual treatment, a stabilization group, Twelve-Step meetings, breath and urine testing, relapse prevention groups, family education groups (which may include other members of the client’s support system), and conjoint or couples counseling (with a spouse or significant other). The second phase lasts an additional six months and involves a weekly support group and expectation of continued participation in a Twelve-Step program. Individual therapy and conjoint therapy are also available during this phase.

In addition to the cost savings and flexibility that intensive outpatient care affords over intensive inpatient services, it may also have “clinical advantages by allowing patients to practice relapse prevention and management skills while being in a highly structured treatment setting” ( McCaul & Furst, 1994 , p. 254). However, some clients may need relief from the stresses of their current environment to benefit from treatment, and others have psychiatric disorders that may contraindicate outpatient services in this early stage of recovery. Matching clients to the least restrictive treatment suitable to their needs is an appropriate goal of treatment planning.

Day Treatment

Another type of intensive outpatient treatment is known as day treatment or partial hospitalization. One definition of a partial hospital or day treatment program is “a freestanding or hospital-based program that provides services for at least 20 hours per week, and can be used to treat Substance-Related Disorders or can specialize in the treatment of co-occurring mental health conditions and Substance-Related Disorders” ( U.S. Behavioral Health Plan, California, 2010 ). Participation in a day treatment program may last longer than other forms of intensive treatment and is often appropriate for clients who are not—at least at this point—able to function in the community by holding jobs or caring for their families. Some of these clients have both psychiatric disorders and substance use disorders. Others have substantial physical impairments that may require a longer period of rehabilitation or substantial cognitive impairments (from substance abuse or other causes such as traumatic brain injuries) and need additional time to learn relapse prevention, communication, vocational, and independent living skills before complete reintegration to the community can be achieved. Some clients attend day treatment following intensive inpatient chemical dependency treatment or inpatient psychiatric treatment.

Though many programs throughout the country offer day treatment or partial hospitalization services, research on this treatment modality is lacking.  Guydish et al. (1995)  describe a day treatment program called Walden House that was designed for clients with serious alcohol and other drug problems in order to meet the growing demand for substance abuse treatment. It includes individual, group, and family therapy and employment, legal, and other services and can be used as a stand-alone treatment or to help those awaiting residential treatment. The staff and clients are regarded as a surrogate family. The program operates from 8:00 A.M. to 8:00 P.M. on weekdays with more limited weekend hours.  Alterman and McLellan (1993)  also discuss a Veterans Administration (VA) day hospital program for those addicted to alcohol or cocaine.

Effectiveness of Intensive Treatment

In a review of the effectiveness of Minnesota model intensive treatment programs,  Cook (1988b)  found few rigorously conducted studies. He did conclude that “despite exaggerated claims of success, [the Minnesota model] appears to have a genuinely impressive ‘track record’ with as many as two-thirds of its patients achieving a ‘good’ outcome at 1 year after discharge” (p. 746). Many questions about the effectiveness of intensive treatment remain unanswered. For example, when patients do well, are particular components or combinations of components of these programs the keys to their success, or is the total package of services necessary to promote recovery?

Interest in whether inpatient treatment produces better results than outpatient treatment spawned several notable studies in the 1980s and 1990s. These studies generally showed no differences in the outcomes associated with inpatient and outpatient care (including partial hospitalization and day treatment) of alcoholics ( Connors, 1993a ;  McKay & Maisto, 1993 ;  NIAAA, 1987 ). Even one group of researchers who found that hospital treatment for alcoholism produced better overall results than community treatment wrote, “Noteworthy . . . were the findings that the IC (in community) treatment was effective for some patients and that both IH (in hospital) and IC treatment were relatively ineffective for other patients” ( Wangberg, Horn, & Fairchild, 1974 , p. 174). A meta-analysis of drinking outcomes in 14 studies found a slight positive effect for inpatient over outpatient alcoholism treatment at three months following treatment but not after three months ( Finney & Moos, 1996 ).  Finney, Hahn, and Moos (1996)  note that while outpatient programs are appropriate for many people with alcohol problems, those with more serious psychiatric, medical, and social disadvantages should be afforded the necessary inpatient or other residential services (also see  NIAAA, 2000 ). Treatment setting may be more important for those with drug problems other than alcohol because of its relationship to treatment retention. For example, studies of treatment for cocaine addiction show “greater engagement and retention of patients in inpatient settings,” although treatment completers did as well regardless of whether they were treated in an inpatient or outpatient program ( McLellan & McKay, 1998 , p. 330, italics in original).

Residential Programs

Also on the continuum of care are a number of residential services. These communal living environments are intended to increase the likelihood that individuals will remain clean or sober during the early days of recovery. For some individuals, they may also be the preferred type of residence in the long-run, since living alone can be isolating and may promote drinking or drug use. Residential services include halfway houses, therapeutic communities, domiciliaries, and missions. Each has a unique role in helping people with alcohol and drug problems.

Halfway Houses

Halfway houses (sometimes called rehabilitation facilities or recovery homes) are another part of the continuum of care for many alcoholics and addicts (see  White [1998]  for an early history of halfway houses).  Rubington (1977)  defined a halfway house “as a transitional place of indefinite residence of a community of persons who live together under the rule and discipline of abstinence from alcohol and other drugs” (p. 352). These houses may be publicly subsidized, privately owned, or church sponsored.

Some halfway houses are solely for those who are mandated to become residents by the criminal justice system. Many halfway house residents have lost their jobs and financial assets, are estranged from family and friends, or lack social and independent living skills, and turn to halfway houses when they lack other living arrangements. In other cases, individuals specifically seek a living environment that is focused on supporting their sobriety. Despite their presence in many communities, halfway houses per se have attracted little scholarly study.

The structure of halfway houses and the services they offer vary considerably (see, for example,  Orford & Velleman, 1982 ). Some are highly structured, with a specific treatment regimen that consumes almost all the residents’ time. Others are loosely structured and are more like boarding homes with some supervision or requirements to get a job and attend mutual-help group meetings. The structure of many halfway houses falls in between these two extremes and incorporates treatment and mutual-help groups along with expectations that residents seek and maintain employment. The staff and their credentials also vary. Some halfway houses are supervised 24 hours a day by managers who are themselves in recovery. Some employ professional staff (therapists, counselors, etc.). In some halfway houses, a case manager or primary counselor coordinates the services each client needs.

Some halfway house programs require residents to have at least weekly individual counseling sessions and to participate in group treatment. Seeing that clients get a job is often a priority in these programs ( Campbell, 1997 ). Other services may include education about independent living skills and communication as well as nutritional counseling, exercise, and instruction on maintaining good health and mental health. Participation in recreational activities and developing social skills is usually encouraged because of the desocialization of clients whose problems are severe enough to warrant referral to a halfway house. Attendance at Alcoholics Anonymous or other mutual-help meetings, often several times a week, is a frequent requirement. Halfway house staff often work closely with other community agencies to ensure that their clients receive services such as vocational rehabilitation and health care. Residence in a halfway house provides an opportunity to address many client needs.

A resident may be admitted to a halfway house on the recommendation of an individual staff member, or there may be a client staffing where the client meets with a small group of staff members who ask the client questions about his or her motivation to enter the halfway house and determine whether to offer the individual admission (see  Rubington, 1985 ). Residents must usually agree to participate in all halfway house activities and to abide by other rules, which include no drinking of alcohol and no use of drugs except as approved by his or her doctor or medical staff. Residents are generally not allowed to keep their own medications but are given access to them by staff. Other rules are no violence and no sex in the house. Residents are usually obligated to report violations of the rules by other residents. They are also expected to keep their personal living area clean, and general household chores such as cooking and cleaning are often shared or rotated. Visitors and personal telephone calls may be restricted to specific times. Passes or leaves of absence are generally limited at first, but increase as the residents makes progress. Policies regarding readmission after rule violations, especially drinking or drug use, differ among programs, with some more lenient than others. As residents move through recovery, they usually take on more responsibilities and earn more privileges in the halfway house.

Some programs have resident or community governments. Residents may take turns chairing weekly meetings held to discuss and solve problems in the house, such as neglecting chores, drinking or drug use, and interpersonal conflicts between residents. Resident governments are established to help clients learn rational means of problem solving. Staff may participate in all or some of these meetings to work out problems, especially conflicts between residents and staff. This gives staff an opportunity to model problem-solving and discussion skills for residents.

The length of time clients are allowed to remain in halfway house programs varies and may be 30, 60, or 90 days or more. If demand for admission is high, the maximum stay may be shorter. In other houses, the stay is open ended because the program’s philosophy is that residents need a period of treatment commensurate with the length and severity of their chemical dependency before they can achieve sufficient stability to live independently. In some cases, the stay may be determined by the terms of a resident’s probation or parole.

Clients may be charged modest fees for their room, board, and treatment. In addition to the need to defray program costs, reasons commonly used to support charging halfway house residents are that (1) it helps them learn or relearn responsible behavior, (2) services that involve a fee are more highly valued than those that are free, and (3) those individuals who are not interested in treatment will be deterred from entering the program. Some clients are employed and pay the fees themselves. Others may be sponsored for a period by treatment or rehabilitation agencies such as a state’s vocational rehabilitation program. Many halfway houses serve men only or women only, but some are co-ed. Some halfway houses are especially for mothers and allow them to bring their young children. The children usually receive services, too.

One particular recovery house model is Oxford House, established in Silver Spring, Maryland, in 1975 ( Molloy, 1992 ). 1  Oxford Houses serve those with alcohol or other drug problems. They do not use paid staff and are financed and democratically run by the residents. The Oxford House charter requires that a member who uses alcohol or drugs be expelled immediately. Residents elect the officers of each house who serve six-month terms. New residents are admitted upon approval of at least 80 percent of the current residents. There is no minimum length of clean or sober time required before a new resident can be admitted and no maximum length of stay. Although Oxford House is not affiliated with Alcoholics Anonymous or Narcotics Anonymous, residents are expected to participate in these programs. Each home houses 6 to 15 residents. There are homes for men, women, and women with children (co-ed homes are not permitted). Any group of recovering individuals can apply to start a house. The federal Anti-Drug Abuse Act of 1988 provides loans for those wishing to start new houses. There are several hundred Oxford Houses in the United States.

Effectiveness of Halfway Houses

Rigorous studies of halfway house programs are lacking, though there is “evidence that chronic alcoholic patients have a reasonable chance for recovery if they are willing to become involved in a residential treatment setting” ( Fischer, 1996 , p. 163). Van Ryswyk and colleagues (1981–82) analyzed data on 641 former residents of eight halfway houses. Compared with their preadmission functioning, these individuals had fewer detox admissions, used public assistance less, had fewer encounters with the criminal justice system, had greater abstinence, and had better employment outcomes.  Hitchcock, Stainback, and Rogue (1995) present some evidence that military veterans discharged from inpatient alcohol and drug treatment to a halfway house had better retention and completion in a VA after-care program than those discharged to live in the community independently or with family or friends.

Another study, based on a sample of 499 indigent clients with serious alcohol and drug problems, found they had greater increases in earnings when they participated in 28 days of inpatient treatment followed by 60 days of halfway house treatment, rather than inpatient treatment only ( Wickizer, Longhi, Krupski, & Stark, 1997 ). These gains were also greater compared to clients who received outpatient treatment. In a more recent study, clients dependent on alcohol, drugs, or both participating in either a day hospital program or community residential treatment fared similarly in abstinence outcomes at six and twelve months ( Witbrodt et al., 2007 ).

One group of researchers also studied 150 individuals who were assigned randomly to an Oxford House recovery home or usual after-care following inpatient treatment. After two years, those who lived in Oxford Houses for at least 6 months had less substance abuse than those who stayed less than 6 months and those assigned to usual after-care, which consisted of outpatient treatment, mutual-help groups, or other services ( Jason, Olson, Ferrari, & Lo Sasso, 2006 ;  Jason, Olson, Ferrari, Majer, Alvarez, & Stout, 2007 ). Other positive benefits accrued in the areas of employment, criminal activity, and child custody.

Therapeutic Communities

While halfway houses were originally designed to serve alcoholics, therapeutic communities (TCs) have focused on treating those addicted to heroin and other illegal drugs. Traditional TCs are highly structured residential programs that provide learning experiences in which changes in the user’s conduct, attitudes, values, and emotions are continuously monitored and reinforced ( De Leon, 1986 ;  2000 ). The first therapeutic community for drug addicts, Synanon, began in 1958. It combined ideas from Alcoholics Anonymous and therapeutic communities for those with psychiatric problems. (See  De Leon, 1986 ;  Kurth, 2009 ;  Ray & Ksir, 1990 ;  White, 1998  for descriptions of TCs.) Daytop Village and Odyssey House are also well-known TCs. TC residents often began drug involvement at a young age, which has stultified mastery of the developmental tasks of adulthood (see  Box 6.3 ). As a result, TCs are likely to focus on habilitating as well as rehabilitating residents ( De Leon, 2008 ;  Gerstein & Harwood, 1990 ). These residential programs may be thought of as a combination of intensive treatment and residential care. The recommended stay is often longer than in halfway houses, though in recent years the recommended stay has decreased from as much as two years to 9 to 15 months ( De Leon, 2008 ).

TC staff members are often addicts with substantial periods of recovery. TCs rely on group process and peer pressure to get residents to address their problematic behaviors. Reality therapy ( Glasser, 2000 ) is often the underlying treatment philosophy. Confrontation is used to break the denial that is generally a part of chemical dependency. Many professionals are initially quite surprised at the intensity of the confrontation in individual and group counseling sessions, but both TCs and other chemical dependency treatment programs seem to have toned this down in recent years. The dropout rate from TCs is high, due perhaps to the rigors of these programs ( De Leon, 1999 ,  2000 ,  2008 ). Many halfway houses expect clients to obtain jobs quickly, but therapeutic communities tend to believe a longer period of treatment is needed before the resident is capable of holding an outside job and has earned the privilege of working outside the facility. To teach employment behaviors and skills, some TCs operate cottage industries where residents work in enterprises such as a greenhouse, duplication service, and other small business.

Clients start with few privileges and earn additional privileges as they progress in the TC program. New residents are often assigned the most menial household chores. Progress is measured by abstinence from drugs, active participation in treatment, and adherence to program rules. Urine “drops” may be used to monitor abstinence. Moving up to the next level in the program may be based on a vote of residents and staff. Residents may graduate to become staff of therapeutic communities.

To address criticisms of high dropout rates, inhibition of residents’ autonomous functioning, weak community ties, misdiagnosis and improper treatment of mental illness, and potential for abuse and mismanagement because leadership is invested in a few individuals, today’s TCs have modified their practices to better serve residents ( White, 1998 ). In fact, there is no single TC model, as programs have undergone many modifications due to funding realities and changing client populations, with some TCs focusing on serving women (including those with children), youth, and people dually diagnosed with mental illness and drug disorders ( De Leon, 2000 ).

BOX 6.3 A Therapeutic Community Resident

Susan Murphy was 18 when she entered a therapeutic community. She was skinny with long, scraggly black hair and a tattoo of a former boyfriend’s name on her left hand. She had run away from home at least a dozen times during her teen years because she never got along with her mother and stepfather. Susan spent many nights on the streets and in runaway shelters. She was a high school dropout and had never held a job for more than a few weeks. Susan was convinced by staff of a criminal justice diversion program to enter the TC after she was picked up on a vagrancy charge and her “rap” sheet indicated several other infractions. Susan had used many types of drugs. She was particularly fond of amphetamines but did not want to start mainlining drugs like her current boyfriend. Susan hated the TC at first and found it difficult to take the strong feedback from staff and other residents about her attitude of blaming others for her problems. She almost left several times, but she did manage to remain for a year and earned a GED along with 12 months of “clean” time. Susan is now a graduate of the TC and is in vocational school learning computer technology. She attends Narcotics Anonymous regularly and likes to sponsor new members.

Among the developments in the history of therapeutic communities is the growth of modified TCs in correctional settings, where staff has much greater control than in more traditional TCs ( Springer, McNeece, & Arnold, 2003 ). In fact, TCs have been called “the primary treatment for substance abuse in American prisons” ( Wexler, Melnick, Lowe, & Peters, 1999 , p. 3). Prison-based TCs include New York’s Stay’n Out program( Wexler & Williams, 1986 ) and Oregon’s Cornerstone program ( Field, 1992 ).  Gerstein and Harwood (1990)  call today’s therapeutic communities “a remarkable merger of the therapeutic optimism of psychiatric medicine and the disciplinary moralism of the criminal perspective” (p. 352).

Effectiveness of Therapeutic Communities

In summarizing the literature on the effectiveness of TCs,  De Leon (2000 ,  2008)  notes that (1) they result in improvements in employment, criminal behavior, alcohol and drug use, and psychological adjustment; and (2) longer stays are associated with better outcomes. The research designs used in many studies do not allow concluding with confidence that this treatment approach is superior to others in reducing drug use or providing other benefits for residents, including those who have been incarcerated ( Smith, Gates, & Foxcroft, 2010 ;  Mitchell, Wilson, & MacKenzie, 2006 ). A Campbell Collaboration review did find that with regard to incarcerated participants, “programs that intensively focus on the multiple problems of substance abusers, such as TCs, are most likely to reduce drug use and recidivism” (Mitchell et al.). Others also note that “when combined with close supervision and monitoring after clients leave the TC, this model does seem to work for certain ‘hard core’ addicts who have failed in other programs” ( Springer et al., 2003 , p. 123).

The effectiveness of TCs for incarcerated individuals may also be related to participation in services post-release ( Olson, Rozhon, & Powers, 2009 ). One study of 448 subjects at 18 months after their release from prison compared the effects of (1) a prison-based TC called KEY, (2) a work-release TC with an aftercare component called CREST, (3) the Key TC followed by CREST, and (4) a comparison group that did not receive TC treatment (although some did receive some type of service) ( Inciardi & Martin, 1997 ). The KEY and no-TC treatment groups had similar outcomes and did not fare as well as the other two groups. The CREST and KEY-CREST participants were more likely to have had no arrests and no drug use, indicating the utility of the re-entry work-release TC program as part of the TC treatment continuum. However, a five-year follow-up study of 690 individuals who participated in a multistage TC in Delaware that included residential treatment during work release prior to community release found that TC graduates had higher probabilities of being drug free and arrest free whether or not they participated in aftercare compared to a no treatment group that participated in regular work release ( Inciardi, Martin, & Butzin, 2004 ).  Welsh (2007) also found evidence of drug treatment TCs’ effectiveness two-years post release, even without an aftercare participation requirement.

Domiciliaries

A domiciliary, another type of residential facility, generally assists those with severe physical or mental debilitation from alcohol or other drug dependency. Some individuals referred to a domiciliary need an extensive period of recovery before they move to a halfway house. For others, the domiciliary will become their long-term home because the permanent nature of their impairments make a successful return to independent living unlikely.

Domiciliaries usually have 24-hour staff supervision. Residents are given responsibilities or participate in activities commensurate with their abilities. The care provided may be largely custodial but there may be some group treatment, especially to promote socialization. Domiciliaries are generally more lenient in reaccepting a client following alcohol or drug use than halfway houses or therapeutic communities. The U.S. Department of Veterans Affairs operates domiciliaries and supported housing programs for homeless veterans debilitated by substance use disorders or other physical and mental disorders ( Ross, Booth, Russell, Laughlin, & Brown, 1995 ). Some communities also support domiciliary-type facilities. Residents whose conditions deteriorate to the point that they become nonambulatory or need psychiatric or nursing home care are referred to appropriate facilities.

Effectiveness of Domiciliaries

In one of the few studies that mentions domiciliaries,  Ross et al. (1995)  found that male veterans who entered a domiciliary following a 28-day inpatient alcoholism treatment program were more likely to be abstinent 12-months later compared to those who were discharged to the community. The groups did not differ on alcohol-related hospital re-admissions, and the study controlled for baseline characteristics. At baseline, those who entered the domiciliary had less social support and more depression. Following the domiciliary stay, they had increased social support and reduced depressive symptoms.

Shelters and Missions

Shelters and rescue missions operated by the Salvation Army, religious organizations, and other entities have long assisted those who are homeless, transient, or living on the streets due to a variety of problems such as substance abuse, mental illness, or inability to secure a job ( Fagan, 1986 ;  Katz, 1966 ;  White, 1998 ). Some of these facilities are better classified as halfway houses because residents spend several months at them receiving treatment and working (perhaps in one of their thrift shops). A religious program is often a component of services. In many cases, the stay at one of these facilities is brief (a night or two). In street lingo, brief stays are often referred to as “three hots and a cot” (three meals and a bed in which to sleep). Those staying overnight receive an evening meal and may be expected to attend a prayer or spiritual service designed to motivate them to find a new way of life. Following an early breakfast (sometimes toast, coffee, and grits), they are generally expected to leave the premises, and those planning to spend another night usually are not permitted to return until evening check-in time. They may be assisted in finding a few hours or a day’s work. The cost of staying overnight might be a few dollars. Some facilities do not charge, or they may give a free night once every month or two.

The staff of public and not-for-profit substance abuse programs frequently refers individuals with alcohol and drug abuse problems who have no other residence or who decline treatment to these facilities. These individuals may stay at a mission or shelter while they try to find a job, make arrangements to get a bus ticket home if they are from another area, or await admission to an inpatient chemical dependency treatment center or a halfway house.

Chemically dependent individuals also utilize homeless shelters. Missions and shelters generally do not admit those who are obviously intoxicated or who are experiencing serious withdrawal symptoms. Some missions have been criticized for their moralistic approach to substance abuse and for their exploitation of clients’ labor; however, they have historically provided a safe haven for those who would otherwise be sleeping on the streets or in the woods ( Jacobson, 1982 ).

Effectiveness of Shelters and Missions

Evaluating the effectiveness of shelters and missions in helping people with alcohol or drug problems is particularly difficult because of the transient nature of the clientele served by these programs.  Jacobson (1982)  concluded that despite the limited number of studies, experience shows that the short-term effects of shelter residence are generally positive. Namely, drinking is interrupted, meals and safety are provided, and individuals may be referred to other helping resources such as employment services, medical services, halfway houses, mutual-help and spiritual programs, or other services.

Outpatient Services

Outpatient services are the most often used component of the continuum of care. Some clients use outpatient services following detoxification, intensive treatment, or halfway house services. Those with less severe impairments may begin treatment with this component. Outpatient services are usually some type of counseling—individual, couple, family, or group. The theoretical orientations and treatment philosophies of those who provide these services vary as does the frequency with which clients receive outpatient services. Sessions are often scheduled weekly but may be more or less frequent and taper off as progress is made.

The content of outpatient treatment sessions is quite similar to intensive and residential treatment. Examples are how to remain alcohol and drug free, dealing with loneliness and sadness, fostering positive social relationships, and increasing self-esteem. Other services may involve teaching relaxation or stress-reduction techniques. Issues such as previous physical or sexual abuse may also be addressed. Since no single human service professional is equipped to treat all the problems clients may present, referral to other professionals may be needed.

Many types of providers offer outpatient chemical dependency services including psychiatrists, psychologists, nurses, social workers, marriage and family therapists, various types of counselors (such as rehabilitation and pastoral), and chemical dependency counselors (some who have degrees in the helping professions and others who do not). State laws regulating these providers vary. Increasingly, state laws (and community norms) have required that human service professionals, including those who treat people for alcohol and drug problems, be licensed or certified. State laws and insurance companies determine which professionals can collect third-party insurance payments for their services.

Outpatient services are provided by (1) public agencies, (2) private, not-for-profit organizations, (3) private, for-profit corporations, and (4) churches or other religious organizations. Some outpatient programs are stand-alone entities; some are attached to hospitals; others are part of community mental health centers, community alcohol and drug treatment centers, or faith-based organizations. Private practitioners in the chemical dependency field may also offer their services in individual or group practices. Health maintenance organizations (HMOs) and employee assistance programs (EAPs) may offer outpatient chemical dependency services directly, using their own personnel, or through arrangements with community agencies or individual practitioners.

Like other services, outpatient chemical dependency treatment may be covered under the individual’s health care plan, or the client may pay for it directly. In public or not-for-profit programs, a sliding fee scale may be used, or clients may not be charged if they lack health insurance or other means to pay. Private practitioners usually charge fees based on local market rates; some use sliding scales or provide some treatment on a pro bono basis as a community service.

Individual Counseling

Individual outpatient counseling involves only the client and the human service professional. The preference in chemical dependence treatment has been for group therapy with individual treatment used as an adjunct ( NIAAA, 1990 ;  Rounsaville, Carroll, & Back, 2009 ) or to treat specific problems such as trauma or sexual dysfunction that are not necessarily appropriate for the chemical dependency treatment group.

Although group treatment is often recommended, there are reasons for using individual therapy ( Rounsaville et al., 2009 ;  Washton, 2005 ). Clients may feel that individual treatment will be more effective, as it permits more focus on the individual’s problems and greater flexibility to do so. Some clients have difficulty engaging in the group process and may find it threatening; protecting one’s anonymity may also be an issue. Clients may also find it easier to schedule individual appointments, and practitioners may not have enough clients at a given time to establish a treatment group. This is especially true in rural areas, where the lack of anonymity in groups is also a problem.

Group Treatment

Group treatment is frequently offered as the “treatment of choice” to those with alcohol and drug problems. In addition to its economy, group therapy can reduce clients’ denial and increase acceptance of alcohol and drug problems and meet their “intense needs” for “acceptance and support” ( Levine & Gallogly, 1985 ; see also  Washton, 2005 ). Clients also receive comfort and support from others with the same problem; group members with greater recovery experience serve as role models and offer coping strategies, and admission of one’s problems to the other members may promote abstinence and deter relapse ( Rounsaville et al., 2009 ). For those who have few positive social contacts, it can help restore relationships with others ( Brook, 2008 ;  Morrell & Myers, 2009 ). See  Box 6.4.

Groups are almost always a component of intensive inpatient chemical dependency treatment programs. Outpatient programs also offer them. There are many forms of group therapy, and a number of theoretical approaches used in individual therapy have been adopted for group treatment such as cognitive behavioral therapy ( Morrell & Myers, 2009 ) and the stages of change or transtheoretical model ( Velasquez, Maurer, Crouch, & DiClemente, 2001 ).

The composition of outpatient chemical dependency treatment groups varies. Groups usually have several members, but more than 12 is generally considered too large to allow everyone to participate. Participation may be restricted to clients who share certain characteristics. For example, a group may be composed of only male or only female members, gay men or lesbians, or those in a particular age group. There is usually one group leader but sometimes two. Co-ed groups may have male and female leaders, but when groups are for men only or women only, someone of the same gender is usually the leader.

Groups may be closed or open ended. In a closed-ended group, members usually start together and contract for a certain number of sessions. At the end of the sessions, members may be asked if they wish to contract for additional group sessions. An advantage of the closed-ended group is continuity of membership, but if there are many dropouts, those remaining may become discouraged and the number may dwindle below what is necessary to carry on effective group sessions. In an open-ended group, members may join at different times. A commitment to attend a specific number of sessions may not be required. Although open-ended groups may allow members new to sobritey to benefit from those who have more experience in managing sobriety, disruptions may occur as members leave and new members are introduced to the group and the group process.

BOX 6.4 An Outpatient Client

Frank Villa, a 26-year-old Mexican American male, was friendly and cheerful when sober—someone who was always described as a nice guy—but his wife would not put up with his drug use and left him. To make matters worse, he flunked out of college after changing majors three times and got a DWI. He was out of work and had little choice but to move in with his mother and to try to stay away from alcohol, marijuana (his favorite drug), and whatever else came his way. Frank got a part-time job with a moving company and also enrolled part time at the junior college. He joined an outpatient group for young people at the community alcohol and drug treatment program after deciding it was time to “grow up.” Frank enjoyed attending the group. The discussions of topics among his peers always seemed relevant to him, and the socialization before and after group sessions helped assuage his loneliness. Frank felt he really fit in with the group members, unlike those at school and at work, who had no idea what it was like to have a drug problem. He also attended AA and NA a few times a week. Frank would stay off alcohol and drugs for a few months and then get high again. After his mother became distraught over his behavior and other family members asked him to leave her home, Frank got a girlfriend he met at NA to let him move in with her. With her urging, he went back to his therapy group and to AA and NA. Frank eventually celebrated a year of sobriety. Friends have told him he would make a good counselor. After giving it serious consideration, he is now working on his licensure in chemical dependency treatment.

The amount of structure leaders of substance abuse treatment groups impose varies; however,  Washton (1997)  notes that “successful group treatment relies heavily on the active leadership, direction, and education supplied by the group leader” (p. 445; also see  Brook, 2008 ). In more structured groups, the leader often presents topics for discussion and uses preplanned exercises. In less structured groups, the leader may ask clients to present topics for discussion that are of current concern to them.

Group treatment is also provided to the loved ones of chemically dependent individuals. Some groups include all types of family members—spouses or other partners, children who are old enough to participate, parents, and siblings. Membership in other groups may be limited to spouses or other partners, to young children, or to adult children (see  Chapters 10  and  12 ). The goals of these groups are usually to help family members understand the dynamics of chemical dependency, relieve guilt, build self-esteem, avoid enabling, and focus on becoming healthier and happier individuals.

Couples Therapy

Couples therapy, sometimes called marital therapy, is another outpatient service (the term marital is outmoded for many clients, given the range of relationships that people may experience). Couples therapy may occur at any time but is often offered after the client receives initial inpatient or outpatient services and has maintained some sobriety. Before participating in couples treatment, the partner who is not chemically dependent may also have attended educational sessions, individual therapy, or group therapy for family members.

Initially, this form of therapy may help the couple explore how chemical dependency or other problems have affected their relationship. Ventilation of hurt and anger may be important at this stage. The topics may then progress to improving communications, working out problems, and reacting to lapses or relapses should they occur. Couples treatment may help strengthen a relationship, but it may become a forum for determining that the relationship was never satisfactory or that it is not repairable.

Some practitioners treating chemically dependent clients and their partners are marriage and family therapists or are otherwise qualified to treat couples and families. Others are not equipped to do extensive work in these areas and refer clients when these services are needed.

Family Therapy

Still another type of outpatient service is family therapy (discussed more fully in  Chapter 10 ). Similar to couples therapy, family therapy focuses on chemical dependency’s effects on the particular family, reducing family dysfunction, and improving family communications and relationships. Family members may have participated in educational sessions or in family groups before beginning family therapy. All members of the current nuclear family are usually invited to participate, although some may decline to do so. Members of the extended family, such as the parents of an adult chemical abuser, may be included, especially if they are directly enabling the client. The client and extended family members may also be seen together if the client is working to resolve family-of-origin issues.

Multimodal Approaches

Outpatient programs may combine several treatment approaches or modalities. For example, Nathan Azrin and George Hunt developed the community reinforcement approach (CRA) to treat people with alcohol problems ( Meyers, Roozen, & Smith, 2011 ;  Sisson & Azrin, 1989 ). CRA was first used in a hospital setting and later in treating those with alcohol or drug problems on an outpatient basis. This behavioral approach emphasizes positive reinforcement to encourage behaviors such as sober or “clean” living and includes: (1) analysis of antecedents and consequences of substance use to identify alternatives to substance use, (2) for those not ready to adopt a goal of abstinence, help in moving toward this goal and trying a period of abstinence, (3) selecting goals in areas to improve life, (4) behavioral skills (problem-solving, communication, drink/drug refusal) training, (5), skills training to obtain and maintain employment, (6) social and recreational counseling, (7) relapse prevention skills, and (8) relationship counseling to improve the relationship with one’s partner (Meyers et al.).

CRA has also been used with disulfiram treatment (discussed later in this chapter), including a supportive loved one to assist in complying with the disulfiram regimen ( Roozen et al., 2004 ), and with contingency management techniques (i.e., incentives such as take-home doses of methadone and monetary rewards, also described in greater detail later in this chapter) ( Higgins, Tidey, & Stitzer, 1998 ;  Meyers et al., 2011 ). CRA is thus a multimodal approach to chemical dependency treatment that addresses relevant aspects of the client’s life in order to promote abstinence and general well-being. Community reinforcement and family training (CRAFT) is another approach that has received attention because of its focus on getting resistant alcohol and drug users into treatment by helping a family member or other significant individual modify the environment to reward sobriety (Myers et al.;  Smith, Meyers, & Austin, 2008 ).

Another multimodal approach used in outpatient addiction treatment is network therapy ( Galanter, 2008 ,  2009a ). It relies on treatment coordination, cognitive behavioral strategies, and social support from family and friends who assist the therapist and help the client abstain from alcohol and other drugs and comply with pharmacological treatments for addiction (e.g., disulfiram). A network usually consists of three or four family members or friends. The client and network members are expected to maintain good relations and work together as a team. Family and friends do not enforce sobriety, but they are supposed to inform the therapist about lack of client compliance. The patient participates in individual therapy as well as initial and periodic subsequent sessions with network members. Participation in mutual-help groups is encouraged.

Brief Interventions and Brief Therapies

Brief and very brief interventions as well as brief therapies are included under outpatient services. Brief and very brief interventions typically involve one to three or four sessions, with each session ranging from a few minutes to one hour in duration( Fleming, 2000 ;  Kaner et al., 2009 ;  McQueen, Howe, Allan, & Mains, 2009 ). Brief interventions have been designed for use in primary health care settings, hospital emergency and trauma departments, and colleges and universities. They have also been used with pregnant women and older adults (see  Fleming, 2000 ;  NIAAA, 2000 ). Brief interventions take a variety of forms, including counseling or advice by a physician or other health or social service professional to reduce drinking, agreements to reduce drinking, monitoring or check-ins in person or by phone, self-help manuals, bibliotherapy (reading materials), and drinking diaries or logs to monitor drinking.

Used alone, the briefest interventions are generally reserved for alcohol misusers or abusers ( McCaul & Furst, 1994 ;  NIAAA, 2000 ). Many individuals seen by professionals in health care or social service settings do not meet the diagnostic criteria for alcohol abuse or dependence, but they may engage in risk or heavy drinking (alcohol misuse), which may portend more serious problems. In the absence of medical conditions that warrant abstention, the National Institute on Alcohol Abuse and Alcoholism ( NIAAA, 2005 ) defines risk or excessive drinking as a score of 8 or more on the Alcohol Use Disorders Identification Test (AUDIT, described in  Chapter 5  of this text) for men and 4 or more for women or as follows:

· For healthy men up to age 65, no more than 4 standard drinks (one standard drink equals 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits) in a day and no more than 14 drinks in a week.

· For healthy women and healthy men aged 65 and older, no more than 3 standard drinks in a day and no more than 7 drinks in a week.

One approach for applying brief interventions is designated by the mnemonic FRAMES, in which the professional provides feedback to the patient or client on his or her drinking risks, recognizes the individual’s personal responsibility or decision to change, provides clear advice about altering drinking habits, offers a menuof change options, counsels in a warm and empathic way, and emphasizes self-efficacy (that the patient or client can do it) ( Miller & Sanchez, 1994 ). The professional also helps the individual establish a drinking goal and follows-up to monitor compliance and provide encouragement. Brief interventions may also be used to motivate alcohol-dependent individuals to seek treatment. Interest has also grown in using brief interventions and brief therapies to reduce drug use. Several manuals or guides for conducting brief intervention for alcohol and drug problems are available ( American Public Health Association and Education Development Center, 2008 ;  Babor & Higgins-Biddle, 2001 ;  NIDA, 2009c ).

Another short-term approach of growing interest for addressing substance use problems is solution-focused brief therapy (see  Berg, 1995 ;  Trepper et al., 2010 ). The premise underlying this social constructivist approach is that the client’s “reality is created through social interaction and validation” (Berg, p. 224). As its name implies, the focus is on solutions, rather than problems. The approach recognizes that the client has at least the beginning solutions to his or her problems and views the therapist and client as collaborators on the client’s (rather than the therapist’s) goals to achieve a successful outcome ( Berg, 1995 ). Treatment may be as brief as a single session. Recovering individuals have also been taught to use this approach to help peers ( Miller, 2000 ). Solution-focused therapy has also been used in group treatment for substance abusers ( Smock et al., 2008 ). Little research is available on solution-focused treatment with people who have alcohol or drug problems.

Effectiveness of Outpatient Services

Gerstein and Harwood 1990 ;  Gerstein, 1999  found that illicit drug abusers have better compliance rates with therapeutic communities and methadone maintenance than with outpatient psychosocial treatments. The Drug Abuse Treatment Outcome Study (DATOS) funded by the National Institute on Drug Abuse included four major treatment modalities—long-term residential, short-term outpatient, outpatient methadone maintenance, and outpatient drug-free treatment. All four resulted in clients using less drugs, but generally speaking, residential and inpatient programs were more effective than outpatient programs in reducing cocaine and heroin use among heroin-dependent clients who were not daily users ( Hser, Anglin, & Fletcher, 1998 ). Modality was not significantly related to reductions in use among daily users.

Group therapy is often used to help people with substance use disorders, but challenges to conducting research on group therapy abound. Methodological improvements have been occurring. For example,  Crits-Christoph and colleagues (1999)  randomly assigned 487 cocaine-dependent individuals who had stable living situations and were not taking psychotropic medications to one of four manual-guided treatments: (1) individual drug counseling plus group drug counseling (GDC); (2) cognitive therapy plus GDC; (3) supportive-expressive therapy plus GDC; or (4) GDC alone. Those who received individual plus GDC (both had a Twelve-Step orientation) improved most on a measure of drug use severity. The study did not address how effective individual therapy alone would have been for the clients. In a study of over 7,000 clients who received substance abuse treatment, researchers found that those who participated in more group than individual therapy had better outcomes ( Panas, Caspi, Fournier, & McCarty, 2003 ).  Weiss, Jaffee, de Menil, and Cogley (2004)  examined approximately two dozen studies that compared group treatment to no group therapy, individual therapy, group therapy plus individual therapy, and/or another type of group therapy. In general, there were no differences in outcomes between group and individual treatment, nor did any particular type of group therapy emerge as superior. It remains debatable as to whether group or individual therapy is superior for treating substance use disorders (see  Morrell & Myers, 2009 ). No one approach to group therapy has emerged as superior, but cognitive behavioral therapy has been studied most often and seems to produce consistently positive results (Morrell & Myers).

Marital or couples and family treatments have also shown promising results. In their meta-analysis of family/couples treatment with an adult or family member who abused illicit drugs,  Stanton and Shadish (1997)  found these approaches more effective than individual treatment, peer groups, and family psychoeducation. They also concluded that effectiveness is equally good whether the drug abuser is an adult or adolescent and that the effectiveness of other forms of treatment can be improved by adding family and couples treatment. Particularly promising was the ability of couples and family approaches to engage and retain clients in treatment. However, there is insufficient evidence to determine whether some schools of family therapy are more effective than others.  Edwards and Steinglass (1995)  also conducted a meta-analysis that showed the effectiveness of family treatment in motivating alcoholics to enter treatment; however, once the individuals were in treatment, family approaches demonstrated only a marginal advantage over individual alcoholism treatment. These authors also noted that greater spousal support for abstinence and commitment to the relationship may contribute to better family treatment outcomes.

In one of the first studies of the CRA in treating alcoholism,  Azrin and colleagues (1982)  found that almost all clients participating in CRA were totally abstinent at six months; however, the married and cohabitating clients also did very well in a group that received the disulfiram compliance regimen only, whereas single clients did much better with the full CRA approach (perhaps because they needed more community support). Continuing research has also demonstrated the benefits of CRA with clients who have alcohol and other drug problems ( Abbott, 2009 ;  Meyers & Miller, 2001 ;  Meyers et al., 2011 ). A review of 11 high-quality randomized controlled trials that compared CRA with “usual treatment” found: (1) in treating alcohol problems, CRA and CRA with disulfiram was more effective in reducing number of drinking days than in producing continuous abstinence; (2) in treating cocaine problems, CRA with incentives (vouchers that can be used to purchase goods or services) was more effective in promoting abstinence; (3) with regard to opioid problems, the evidence is limited that CRA promotes better results for methadone maintenance clients or that CRA with incentives promotes better outcomes for detoxification patients ( Roozen et al., 2004 ). An analysis of four controlled trials of CRAFT showed much higher treatment engagement than Alcoholics Anonymous/Narcotics Anonymous or the Johnson Intervention technique (see  Chapters 5  and  10 ) ( Roozen, deWaart, & van der Kroft, 2010 ).

McCrady and associates (1986) randomly assigned 45 couples to one of three behavioral types of outpatient treatment: minimal spouse involvement, alcohol-focused spouse involvement, or alcohol-focused plus behavioral marital therapy (BMT). A six-month follow-up indicated positive benefits for all groups, with the alcohol-focused plus BMT group generally having the best outcomes, such as a more rapid decline in drinking and greater maintenance of reduced drinking. An 18-month follow-up indicated that adding marital therapy enhanced “treatment compliance, subject’s ability to cope with drinking, marital stability and satisfaction, and subjective well being” ( McCrady, Stout, Noel, Abrams, & Nelson, 1991 , p. 1423).

Work in the Counseling for Alcoholics’ Marriages (CALM) program at Harvard University also supports the use of BMT or behavioral couples treatment (BCT) ( Fals-Stewart et al., 2000 ). In this approach, the couple develops a sobriety contract in which the substance abuser agrees not to use alcohol and/or drugs, and the spouse agrees to support this effort ( O’Farrell & Fals-Stewart, 2000 ). There is also a focus on improving communications skills and encouraging the couple to engage in positive activities together. A meta-analysis of a dozen well-controlled studies found at follow-up that compared to those who received individual treatment, BCT participants used alcohol and drugs less, suffered fewer alcohol- or drug-related consequences, and reported greater relationship satisfaction ( Powers, Vedel, & Emmelkamp, 2008 ). Some evidence also indicates that BCT may result in reduced marital violence ( O’Connor, 2001 ;  Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009 ).

No approach has been studied more than brief interventions, perhaps because they are brief. Kaner et al. (2007) conducted a meta-analysis of 22 randomized clinical trials of brief interventions conducted with primary care patients in various countries whose drinking exceeded recommended levels. The interventions involved 5,800 participants followed for one year or longer. Study results varied, but overall, drinking behavior was lower for experimental compared to control group participants. Where results were available by gender, the meta-analysis confirmed the benefits of brief intervention in reducing drinking among men, but results for women were uncertain due to insufficient research data. Longer counseling provided little additional benefit.  McQueen et al. (2009)  also conducted a meta-analysis of 11 controlled trials of brief interventions with heavy alcohol users admitted to general hospitals, and found the evidence of reduced drinking inconclusive.

No treatment or intervention described in this book is a magic bullet. Substance abuse and dependence treatment professionals are still trying to address the question of what treatment works best for which individuals (see  Box 6.5  entitled “Matching and Combining to Enhance Treatment Effectiveness”).

Medication-Assisted Treatment

Several types of drugs or medications may assist alcoholics and addicts in recovery following detoxification (also see  Chapter 3  of this text). Although no medications promise a cure, some may be helpful in maintaining abstinence, which can also help people engage in the treatment process. We focus on the drugs most often used in helping individuals who are dependent on alcohol and opiates. Though there is tremendous interest in medications useful in treating cocaine and amphetamine dependence, no drug has recognized effectiveness, though several are being studied. In addition, there are no evidence-based drug treatments for marijuana dependence ( Kampman, 2009 ).

BOX 6.5 Matching and Combining to Enhance Treatment Effectiveness

Matching Clients and Services

There are no magic bullets in chemical dependency treatment. Individual studies and meta-analyses tell us about the effectiveness of treatment based on group averages, not about what the effectiveness will be for a particular individual. The American Society of Addiction Medicine’s (ASAM) ( Mee-Lee et al., 2001 ) offers patient placement criteria in the form of a matrix or “crosswalk” for adults and for adolescents. The levels of care for adults are early intervention; opioid maintenance therapy; outpatient treatment; intensive outpatient; partial hospitalization; clinically managed low-, medium-, and high-intensity residential treatment; and medically managed intensive inpatient treatment. The level of care a patient needs is assessed according to the following “criteria dimensions”: intoxication or withdrawal potential; biomedical, emotional, behavioral, and cognitive conditions and complications; readiness to change; relapse potential; and recovery environment. To prevent the use of unnecessary services, ASAM supports “unbundling” services; that is, rather than provide a set package of services to a client based on treatment modality or setting (inpatient, outpatient, etc.), the client should be provided the type and intensity of services that meets his or her needs. Clients should also be reassessed during the course of treatment to ensure they continue to receive appropriate services.

There is considerable interest in how professionals can better match clients to treatment to improve treatment effectiveness ( McLellan et al., 1983 ). One approach is to consider clients’ characteristics and match them to a theoretical approach to treatment that is consistent with their needs.  Litt and colleagues (1992)  attempted to do this by randomly assigning Type A alcoholics (e.g., those with less severe problems) and Type B alcoholics (e.g., those with more severe problems) to two different types of treatment. As hypothesized, based on their needs and coping styles, Type A’sdid better in the “less structured interactional group therapy,” and Type B’s did better in the “more structured coping skills group treatment.”

Other studies have attempted to match clients to treatment based on other personal characteristics—for example, demographic characteristics such as gender, drinking-related characteristics, intrapersonal characteristics, and interpersonal characteristics—to determine their impacts, if any, on client outcomes ( Mattson, 1994 ;  Mattson et al., 1994 ). Believing that client matching offered a useful direction to pursue in improving alcoholism treatment, in 1989, NIAAA launched a rigorous, eight-year, $25 million study called Project MATCH. It involved nine treatment sites run under public and private auspices. A team of prominent alcoholism researchers tested the hypothesis “that more beneficial results can be obtained if treatment is prescribed on the basis of individual patient needs and characteristics as opposed to treating all patients with the same diagnosis in the same manner” ( Nowinski, Baker, & Carroll, 1995 , p. ix).

Treatments provided on an individual, rather than group, basis were selected for practical reasons (e.g., being able to start treating each subject immediately) and methodological reasons (e.g., interest in matching on the characteristics of individual clients, rather than groups of clients). Other important considerations were evidence of the treatments’ clinical effectiveness, potential for discerning matching effects based on previous research, and distinctiveness among the treatments. Three approaches were chosen:

The Twelve-Step Facilitation Approach (TSF) was provided in 12 sessions. TSF “is grounded in the concept of alcoholism as a spiritual and medical disease.” TSF is consistent with Alcoholics Anonymous’s 12 steps and the goal was to foster the client’s involvement in AA. ( Nowinski et al., 1995 , p. x)

Motivational Enhancement Therapy (MET) was provided in four sessions. MET “is based on principles of motivational psychology and is designed to produce rapid, internally motivated change.” Rather than guide the client step-by-step, motivational strategies are used to help clients mobilize their own resources. ( Miller, Zweben, DiClemente, & Rychtarik, 1995 , p. viii)

Cognitive-Behavioral Therapy (CBT) was provided in 12 sessions. CBT is based on social learning theory and addresses the range of the client’s problems, not only drinking. Emphasis is placed on increasing skills and the ability to cope with high-risk situations that may precipitate relapse. ( Kadden et al., 1995 , p. viii)

Each treatment was highly structured and guided by a manual. The approximately 80 professionals providing the treatments were carefully selected, trained, and continually supervised to maintain adherence (fidelity) to the treatment they were to provide. The study was divided into an outpatient arm at five different sites and an aftercare arm following standard inpatient or day hospital treatment at four sites. Clients were assigned randomly to the treatments. The goal of all treatments for all the clients was abstinence from alcohol.

There were some minor differences across the treatments, but on average, in the month following treatment, patients in the aftercare arm were abstinent on 90 percent of the days, compared to 80 percent of the days for those in the outpatient arm ( Project MATCH Research Group, 1997a ). One year after treatment, these figures decreased only slightly. However, among aftercare arm subjects, only 35 percent were totally abstinent throughout the year after treatment, compared to only 19 percent of outpatient subjects. There were no true controls (subjects who received no treatment) with which to compare the results. In addition, patients knew they were participating in a major, nationally funded study and might have tried harder, especially given the large amount of attention paid to them during initial data collection and follow-up) ( “Project MATCH,” 1996 ). At the three-year follow-up, conducted only with outpatient arm participants, nearly 30 percent reported total abstinence in the previous three months; those who reported drinking were abstinent an average of two-thirds of the time ( Project MATCH Research Group, 1997a ,  1997b ,  1998b ). TSF participants had somewhat higher abstention rates (36 percent) than MET (27 percent) and CBT (24 percent) participants. Two motivational variables—readiness to change and self-efficacy—were the strongest predictors of better long-term drinking outcomes.

Only 4 of 21 hypothesized matches were observed (they were for client anger, support for drinking, higher alcohol dependence, and psychiatric severity), but none was particularly robust ( Project MATCH Research Group, 1997a ,  1997b , 1998;  NIAAA, 2000 ). Many methodological and other reasons have been offered to explain why the matches were not more prominent ( Project MATCH Research Group, 1997b ). Others have interpreted the results in a more positive light: that despite what treatment is offered, improvement can be expected regardless of client characteristics if the treatment is well delivered and sufficient attention is paid to the client.

Combining To Improve Treatment Effectiveness

NIAAA decided to sponsor another large research effort called Project COMBINE to study two medications for alcoholism treatment—naltrexone and acamprosate (see the section in this chapter on Medication Assisted Treatment)—in combination with a moderate-intensity behavioral treatment ( Anton et al., 2006 ;  NIAAA, 2001 ;  Zweben, 2001 ). Participants were 1,383 alcohol-dependent volunteers from 11 sites divided into nine groups. Eight groups got medical management (nine sessions designed to promote medication adherence and abstinence that can be delivered in primary care settings) and naltrexone, acamprosate, both drugs, or placebos of one or both drugs. Four groups also got more intensive behavioral counseling provided by alcoholism treatment specialists. This moderate- intensity behavioral treatment is a hybrid of the treatments used in Project MATCH and includes participation of a supportive significant other and/or participation in mutual-help groups. Treatment was more individualized than in Project MATCH, and study participants could receive up to 20 sessions. The ninth group got the behavioral counseling without medications or medical management. During the course of treatment, results were:

1. Drinking was reduced among all groups.

2. In conjunction with medical management, behavioral counseling alone or naltrexone alone produced better results than naltrexone and acamprosate combined or any medication/behavioral counseling treatment combination.

3. Acamprosate was not associated with better results in any group.

However, one-year post-treatment most differences between groups faded, indicating the need for continuing services to maintain treatment gains. The results support the benefits of behavioral counseling and naltrexone in assisting alcohol-dependent individuals. It still leaves open many questions, including whether a medication like naltrexone can be beneficial with less intensive medical management.

None of the medications discussed is recommended for use alone; rather, they are viewed as adjuncts to psychosocial treatment. Some of these drugs are called agonists because they mimic the actions of natural neurotransmitters (brain chemicals). Other drugs are called analogs because their effects are similar to those of another drug but their chemical structures differ slightly. An antagonist drug counteracts or blocks the effects of another drug ( NIDA, 1997 ).

Disulfiram

Better known by the trade name Antabuse, disulfiram was approved for use in treating individuals dependent on alcohol in 1951. Disulfiram is neither an agonist nor an antagonist drug. It is intended to deter impulsive drinking, although it does not curb the desire to drink. Instead, Antabuse is described as “buying time” or as an “insurance policy” because those taking it know they will become violently ill if they drink. Originally, it was hoped that disulfiram would be an answer for many people with alcohol use disorders. The criminal justice system was enthusiastic about its use and ordered many of its alcohol-dependent charges to take the drug if it was not contraindicated by other medical conditions, though such coerced used was questioned on several grounds ( Marco & Marco, 1980 ).

Disulfiram interferes with the normal metabolism of alcohol, resulting in a serious physical reaction if even a small amount of alcohol is ingested (for information on disulfiram see  De Sousa, 2010 ;  Ewing, 1982 ;  Kampman, 2009 ,  Nurse Practitioner’s Drug Handbook, 1998 ;  Suh, Pettinati, Kampman, & O’Brien, 2006 ). Those taking it must avoid all alcohol, including that found in prescription and over-the-counter drugs and other products that may contain alcohol, such as mouthwash and skin lotions. Paraldehyde, which is sometimes used to prevent delirium tremens (DTs) in alcohol-dependent individuals, will also cause a severe reaction. Inhaling alcohol fumes in closed quarters might also cause some reaction. Disulfiram-ethanol reactions may involve a variety of symptoms, including flushing, increased pulse and respiration, sweating, weakness, decreased blood pressure, a severe headache, vomiting, and confusion. In the most severe cases, reactions may result in heart failure and other life-threatening problems, and some deaths have been reported. A patient must be completely detoxified from alcohol before beginning disulfiram treatment.

Disulfiram is contraindicated for those with certain conditions, such as serious mental illness, heart disease, diabetes, epilepsy, and pregnancy. Before beginning this treatment, patients must fully understand the consequences of using alcohol while taking disulfiram. It should not be given to those who are intellectually unable to appreciate these consequences. Patients should also be aware that if they do decide to return to drinking, they must allow up to two weeks following the last dose of Antabuse to avoid a reaction. Since serious disulfiram-ethanol reactions can occur, patients should be screened for their desire to take this drug.

Side effects of disulfiram (not related to the ingestion of alcohol) may include skin eruptions or rashes, drowsiness, headaches, and reduced sexual performance. These symptoms often abate following an initial period of adjustment to the drug, or the dosage may be reduced to prevent these symptoms. More severe effects, such as neuritis and psychoses, generally require discontinuing the drug. Patients usually take disulfiram once a day. Originally, it was given in larger doses than prescribed today (disulfiram skin implants were used in some countries), and side effects and complications from reactions were more severe. It was then determined that lower doses were also effective. Patients should carry a card with them indicating that they are taking disulfiram to alert medical personnel should they have a reaction or other medical emergency. Some patients do attempt drinking while on disulfiram and usually end up in a hospital emergency room. Although this description of disulfiram may sound frightening, many alcohol- dependent individuals have used it, apparently successfully ( NIAAA, 2005 ;  McNichol & Logsdon, 1988 ). There is also interest in the use of disulfiram to treat cocaine dependence.

Methadone

Methadone is a synthetic narcotic agonist drug. In addition to its use in narcotic detoxification, it is also used in longer-term chemical dependency treatment as a substitute for the opioid drugs. Methadone’s effectiveness in treating opioid addiction was demonstrated in the mid-1960s, and it was approved for this purpose by the U.S. Food and Drug Administration in 1972 ( Rettig & Yarmolinsky, 1995 ). According to the  Centers for Disease Control (2002) , methadone blocks opiates’ euphoric and sedating effects, relieves cravings for opiates that can lead to relapse, and relieves opiate withdrawal symptoms.

Methadone maintenance treatment (MMT) is intended only for those with a severe narcotic dependence. Some use methadone for a short period before completely withdrawing; others use it indefinitely. Methadone can provide people dependent on opioid drugs an opportunity for life stabilization and participation in a wide range of habilitative and rehabilitative services ( Kleber, 2008 ). Although MMT is supposed to be used with other therapeutic services, the extent to which methadone clients participate in other services varies.

Patients or clients typically take a liquid daily dose of methadone (combined with a sweet drink) at outpatient clinics that also offer other services to clients. Patients taking methadone may complain about weight gain and insomnia, but these problems have been attributed to factors such as increased alcohol consumption and to personal characteristics of users rather than to the methadone itself ( Gerstein & Harwood, 1990 ). Methadone maintenance patients may still use alcohol, cocaine, and other illicit drugs, and this must be addressed in treatment ( Rawson, McCann, Hasson, & Ling, 2000 ;  Substance Abuse and Mental Health Services Administration [SAMHSA], 2009 ). The drug use of clients on methadone maintenance is usually monitored through urinalyses.

Many MMT programs use a multidisciplinary team approach to provide comprehensive services to clients and to make decisions such as whether to continue or discharge a client ( New Brunswick Addiction Services, 2009 ). As clients make progress in treatment, they may be allowed to take a Sunday dose of methadone home or to come to the clinic every other day and take a dose home for the intervening day. In the United States, the program’s medical director must make these decisions according to eight criteria outlined in federal regulations, such as no recent abuse of drugs or alcohol, regular clinic attendance, and no known recent criminal activity ( SAMHSA, 2009 ). In 2008, 1,132 opioid treatment programs were operating in the United States, serving about 268,000 clients taking methadone and 4,280 taking buprenorphine, another medication discussed in the next section of this chapter ( SAMHSA, 2010 ).

Methadone is helpful in deterring addicts from pursuing illegal activities to support their drug habits and allows them to lead more “normal” lives, but its use remains controversial even with its 40-year history ( Centers for Disease Control, 2002 ;  Kleber, 2008 ;  Rawson et al., 2000 ). Detractors argue that it replaces one addictive drug with another, rather than promoting a goal of abstinence.  Hall, Ward, and Mattick (1998)  justify making methadone available because of the difficulties that addicts encounter in remaining opioid free, the failure of abstinence-oriented programs to retain addicts in treatment, and the high mortality associated with chronic opioid dependence.

Methadone maintenance treatment may also help to reduce transmission of the human immunodeficiency virus (HIV), hepatitis B and C, and other diseases ( Centers for Disease Control, 2002 ;  Stine, Meandzija, & Kosten, 1998 ). Even so, controversies persist about the safety and health problems of methadone maintenance and how frequently users sell it to obtain illicit drugs.  Gerstein and Harwood (1990)  discuss these controversies, including the issue of methadone’s use as a social control mechanism versus its therapeutic value to the individual client (also see  Hall, Ward, & Mattick, 1998 ;  Ray & Ksir, 1999 ). Despite its cost effectiveness due to factors such as reduced crime ( Ling, Rawson, & Compton, 1994 ), some communities do not have methadone maintenance clinics because they do not wish to attract heroin users to their area.

A 1995 Institute of Medicine report questioned the very strict federal controls on the administration of methadone to opiate addicts ( Rettig & Yarmolinsky, 1995 ). New federal regulations issued in 2001 allow “more flexibility and greater medical judgment in treatment” ( “Opioid Drugs,” 2001 , p. 4076). For example, patients who have two years or more of stable experience with methadone maintenance treatment may now have take-home doses of up to 31 days, compared to 6 days with previous regulations. In addition, doses are not restricted to liquid form and may include pill form. The approval process for operating these opioid treatment programs involves a certification and accreditation system overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA), with quality assurance provisions that take into account client outcomes. A stabilized patient may receive methadone from a physician in an office-based practice but only if the physician is affiliated with an opioid treatment (methadone maintenance) program. Although state and program regulations may be more stringent, they are expected to comply with the spirit of the federal regulations.

Buprenorphine

Buprenorphine is an analgesic drug that is related to morphine but is much more potent. In 2002, the FDA approved buprenorphine for treating opiate addiction, and physicians who receive training may use it in office-based treatment. Buprenorphine is a drug that combines agonist and antagonist properties (see  Veilleux, Colvin, Anderson, York, & Heinz, 2010 ). Therefore, it mimics the effects of opioid drugs by acting on the same brain receptors, and it also inhibits the effects of opiate drugs so that they do not produce the same euphoria. Buprenorphine seems to create low physical dependence and a mild withdrawal syndrome that may make it an attractive alternative to methadone, especially for patients who wish to become drug free and transfer to naltrexone (described in the next section) ( Ling et al., 1994 ). Although it provides patients with another treatment option ( Strain, Stitzer, Liebson, & Bigelow, 1994 ), cases of burphrenorphine abuse have been reported (Stine et al., 1998). Buprenorphine is provided in sublingual tablet form and is also available in combination with naloxone(a synthetic narcotic antagonist) in order to reduce buprenorphine’s abuse potential ( Kampman, 2009 ;  Stoller, Bigelow, Walsh, & Strain, 2001 ). The trade name of the combination medication is Suboxone, and it is also available in dissolving film strips.  Ling and colleagues (1994)  note that “some patients will have a level of opioid tolerance higher than can be achieved by buprenorphine because of its ceiling effect” (p. 126), suggesting that methadone may be a better choice for them.

Naltrexone, Acamprosate, and Nalmefene

Naltrexone (trade name ReVia), like naloxone, has played a role in detoxifying those dependent on opioid drugs. Whereas methadone, which is also used in opiate detoxification, is a substitute for narcotic drugs, naloxone and naltrexone reverse their effects. Naltrexone has also been used in the longer-term treatment of those dependent on opiates ( Stine, Meandzija, & Kosten, 1998 ;  Treating opiate addiction: Part II, 2005 ). Naltrexone may also improve treatment outcomes for those dependent on alcohol or cocaine. Naltrexone blocks opioid receptors that may also make the effects of drinking alcohol (as well as taking opioid drugs) less pleasurable ( NIAAA, 2005 ). Patients may therefore consume less alcohol should they begin drinking, and the likelihood of a full relapse may be reduced ( Kampman, 2009 ; NIAAA).

Naltrexone has also being tested in combination with acamprosate, which was approved for use in treating alcohol dependence in the United States in 2004. Acamprosate acts differently on the brain than naltrexone ( Center for Substance Abuse Treatment [CSAT], 2005 ). Indications are that naltrexone is more effective in curtailing drinking once it begins, while acamprosate is more effective in preventing drinking in the first place ( Rösner, Leucht, Lehert, & Soyka, 2008 ) because it may reduce post-acute (protracted) withdrawal symptoms (e.g., insomnia, anxiety, and restlessness) ( CSAT, 2005 ). Acamprosate may have advantages over naltrexone because people with liver disease can tolerate it better.

Nalmefene is another opioid antagonist being tested for use in alcoholism treatment ( Anton et al., 2004 ). It, too, has some advantages over naltrexone, such as the ability to bind to different types of opioid receptor sites and perhaps further reduce alcohol’s reinforcing effects ( NIAAA, 2000 ). It also is reported to have no dose-related association with liver toxicity and to have longer duration of action. In addition to safety features, researchers and treatment providers are looking closely at which drug treatments produce the highest rates of treatment retention and effectiveness.

Effectiveness of Medications

Disulfarim

One view of disulfiram is that for many people, its benefits far outweigh the few risks associated with its use, particularly in light of alcoholism’s devastating impact ( McNichol and Logsdon, 1988 ). Where patients do have improved outcomes, questions often arise as to whether it is patients’ desire and motivation to remain sober ( NIAAA, 1987 ), fear of becoming sick ( Fuller et al., 1986 ), other treatment being received or other confounds that produce the positive result ( Suh et al., 2006 ). In a review of studies, Suh et al. note that patient compliance is poor and results of disulfiram clinical trials with regard to abstention from alcohol are inconsistent. Research on disulfiram’s effectiveness compared to other approaches is debatable ( Garbutt et al., 1999 ). A key factor may be in the patient or client’s motivation to take the medication to assist in maintaining sobriety ( Center for Applied Research in Mental Health and Addiction, 2008 ). Like other forms of treatment, disulfiram may work best for those who want to use it.

Azrin and colleagues 1982 ;  Sisson & Azrin, 1989  found good results using an “Antabuse reassurance” approach in which disulfiram’s benefits are described, a supportive and helpful (rather than authoritarian and coercive) person is used to help ensure compliance, and role rehearsal is used to help address situations in which failure of the client or support person to follow through with the procedure is anticipated. In a controlled six-month study in the United Kingdom,  Chick et al. (1992)  also found better results with supervised disulfiram use, though during the last month of the study there was no difference between the control and experimental groups’ alcohol use. Others reviewing the state of disulfiram use also suggest the benefits of supervision in increasing compliance with disulfiram, and thus its effectiveness ( De Sousa, 2010 ;  Kampman, 2009 ;  Suh et al., 2006 ). The Cochrane Collaboration, which does research reviews of many treatments for substance use disorders, is conducting a new review of disulfiram’s effectiveness. 2  It is yet unclear whether disulfiram is effective in treating cocaine dependence ( Pani et al., 2010 ).

Methadone

More is known about methadone maintenance treatment’s (MMT) effectiveness than about other types of treatment for illicit drug users. MMT has been called the “most effective treatment for opiate addiction” ( Centers for Disease Control, 2002 ;  Kleber, 2008 ). When used properly, the benefits of methadone have been widely reported (Centers for Disease Control).  Gerstein and Harwood (1990)  caution that methadone maintenance is not the answer for all heroin addicts, but in spite of controversies about this treatment, it generally produces favorable results:

There is strong evidence from clinical trials and similar study designs that heroin-dependent individuals have better outcomes on average (in terms of illicit drug consumption and other criminal behavior) when they are maintained on methadone than when they are not treated at all or are simply detoxified and released, or when methadone is tapered down and terminated as a result of unilateral client request, expulsion from treatment, or program closure. (p. 153)

Given individual client differences, higher rather than lower maintenance doses of methadone seem to produce more positive results ( Centers for Disease Control, 2002 ;  Gerstein & Harwood, 1990 ). In a recent systematic review, methadone maintenance therapy was found superior on treatment retention and reduced heroin use compared to drug-free treatments or methadone detoxification only, since participants generally drop out of drug-free maintenance therapies ( Mattick, Breen, Kimber, & Davoli, 2010 ). The benefit-to-cost ratio associated with methadone maintenance is considered substantial, but the Mattick et al. review did not find statistically significant improvements on criminal activity or mortality.

Studies support the belief that clients have better treatment outcomes when they receive psychosocial services along with the methadone ( Amato et al., 2008 ;  Kraft, Rothbard, Hadley, McLellan, & Asch, 1997 ;  McLellan, Ardnt, Metzger, Woody, & O’Brien, 1993 ). However, a large study found that compared to other treatment modalities, methadone programs often provided less counseling and other services ( Ethridge, Craddock, Dunteman, & Hubbard, 1995 ).

With regard to opioid dependence,  West, O’Neal, and Graham’s (2000)  meta-analysis suggested that buprenorphine is generally as effective as methadone; however, methadone-treated patients had fewer positive tests for illicit opioid use.  Mattick, Kimber, Breen, and Davoli (2008)  also found that as a maintenance medication, buprenorphine is more effective than placebo in reducing heroin use, but it was not as effective as methadone, especially when methadone is prescribed in adequate doses.

Naltrexone

Despite interest in medications such as naltrexone to treat alcohol dependence, the treatment community has not adopted them to any significant extent ( O’Malley & O’ Connor, 2011 ;  Thomas, Wallack, Lee, McCarty, & Swift, 2003 ). In early studies,  Volpicelli and colleagues (1992)  and  O’Malley and colleagues (1992)  investigated naltrexone as an adjunct to the short-term (12-week) treatment of alcoholism and found promising results. Among the VA medical patients studied, Volpicelli et al. noted that naltrexone’s primary benefit seemed to be in preventing subjects from drinking in a particularly harmful way (a relapse) once they began to consume alcohol (a lapse).  O’Malley et al. (1992)  also found better outcomes for those who received naltrexone with respect to number of days drinking and relapse, as well as lower severity of alcohol-related problems. Of particular interest in O’Malley’s study is that 61 percent of patients who received naltrexone in combination with supportive therapy were abstinent for the 12-week period, compared with abstinence rates of 28, 21, and 19 percent, respectively, for those who received naltrexone and coping skills treatment, the placebo and coping skills treatment, and placebo and supportive treatment. In addition, both groups of patients receiving naltrexone had relapse rates (defined as five or more drinks on an occasion for men and four for women) that were substantially lower than for the placebo groups.

O’Malley et al. (1992)  suggested that patients may prefer naltrexone to disulfiram, given disulfiram’s side effects if alcohol is consumed, while  Volpicelli et al. (1992)  suggested that the combination of naltrexone and alcohol may cause an aversive reaction of nausea in some individuals similar to disulfiram. Based on retrospective reports,  Volpicelli and colleagues (1995)  found that naltrexone-treated patients indicated less subjective experiences of pleasurable effects (a high) from alcohol than did placebo patients. Likewise,  O’Malley et al. (1996)  found that patients who took naltrexone and drank retrospectively reported less incentive to continue drinking as a reason for terminating drinking, whereas placebo patients who drank reported that they stopped due to negative consequences of drinking. (The groups did not differ on the pleasantness of the first drinking experience.)

A subsequent 12-week trial by  Volpicelli and colleagues (1997)  in a more naturalistic setting showed only modest benefits of naltrexone in reducing alcohol use, and there was no difference in the percentages of naltrexone and placebo subjects who sampled alcohol. Those who were more compliant with naltrexone treatment did have better outcomes, indicating the need to improve patients’ treatment compliance. In an effort to determine if short-term naltrexone treatment has longer-term benefits,  O’Malley and colleagues (1996)  followed patients 6 months after participating in a study that offered them naltrexone or a placebo and either 12 weeks of coping skills or supportive treatment. Naltrexone’s benefits in supporting abstinence diminished quickly after use ceased, indicating that longer-term naltrexone treatment may be needed. However, naltrexone-treated subjects did not drink as heavily and were less likely to meet the criteria for alcohol abuse or dependence at follow-up.  Monti and colleagues (2001)  followed patients for one year after they took naltrexone for 12 weeks. During the 12 weeks, they found that naltrexone resulted in less alcohol consumed once drinking was initiated, but naltrexone and placebo groups had equal numbers of relapsers and only those who were more compliant with the medication showed significant effects. Naltrexone’s effects were not sustained after patients stopped taking it. In fact, those who took naltrexone were more likely to relapse than those in the placebo group in the three months after the medication trial ceased.

As noted in  Box 6.5  on pages 141–143, naltrexone produced positive results in Project COMBINE while acamprosate did not (almost all study participants also received medical management to help them comply with the medication treatments). One meta-analysis of 24 randomized clinical trials found that naltrexone resulted in significantly fewer relapses during short-term treatment, but not on initiation of drinking ( Srisurapanont & Jarusuraisin, 2005 ); however, another meta-analysis found naltrexone effective in promoting abstinence and in preventing heavy drinking once drinking commenced (Leucht et al., 2008). The latter meta-analysis found acamprosate was more effective than naltrexone in preventing initiation of drinking, while naltrexone was more effective in preventing a lapse (drinking) from becoming a relapse (heavy drinking). More study is needed to determine for whom these medications are useful, how long treatment should be continued, and under what conditions, such as their use with psychosocial treatments.

Aftercare

Aftercare, also known as continuing care ( McKay & Hiller-Sturmöhfel, 2011 ), the sixth component of the treatment continuum, is an extension of intensive treatment, residential, and/or outpatient programs. Aftercare provides an opportunity for program staff to assist clients in monitoring their progress and to address problems and obstacles to maintaining recovery before they result in serious consequences. Aftercare services are provided in many ways. Individual sessions may be used but group meetings may be more common (McKay & Hiller-Sturmöhfel). Telephone contacts may also be used. Clients may participate weekly, biweekly, monthly, or bimonthly, depending on the program or on the clients’ needs. Some private treatment centers charge a flat fee for services, which includes participation in an aftercare program. In selecting a treatment program, the Center for Substance Abuse Treatment recommends asking about whether the program includes long-term aftercare. Clients participating in aftercare connected to treatment programs are usually encouraged to participate in mutual-help groups as well.

Preventing Relapse

Perhaps the most important part of aftercare is learning and practicing the skills needed to prevent lapses and relapses and to manage them should they occur. A key to teaching relapse prevention seems to be increasing clients’ perceptions that they can successfully cope with situations that pose risks of drinking and drug use ( Annis & Davis, 1988 ;  Greenfield et al., 2000 ;  NIAAA, 1990 ). Authors who have written extensively on relapse prevention generally recommend a number of cognitive and behavioral techniques to help clients maintain the gains made in treatment ( Daley & Salloum, 1999 ;  Douaihy, Daley, Stowell, & Park, 2007 ;  Gorski, 2000 ;  Gorski & Miller, 1986 ;  Marlatt & Gordon, 1985 ;  Quigley & Marlatt, 1999 ). Clients generally exert considerable effort to alter their lifestyle to achieve sobriety, and considerable planned effort is often also needed to maintain sobriety. Clients are taught to identify their behaviors and factors such as high-risk situations and negative emotional states (e.g., anxiety, depression, social pressure, family conflicts), referred to as triggers, that usually precede or signal their desire to drink or use drugs or their actual use of alcohol or (Daley & Salloum; Gorski & Miller; Marlatt & Gordon). Clients then learn techniques or coping skills to avoid or defuse the particular situations that threaten their sobriety ( Huebner & Kantor, 2011 ). For example, a trigger may be a fight with a spouse, which may be defused by teaching clients anger-control techniques, such as absenting themselves from the situation until they have cooled off and can discuss the problem rationally. Practicing relaxation and stress-reduction techniques and other healthy lifestyle habits can also be useful in avoiding negative states and preventing relapses and are essential components of one’s aftercare program (Marlatt & Gordon).

Marlatt and Gordon (1985)  suggest that clients also develop plans to follow if drinking or drug use does occur, such as teaching them that consuming a small amount of alcohol or drugs (which some call a lapse or slip) need not necessarily result in a full-blown relapse and that it is possible to take measures to avert a relapse. Contracting may be used to accomplish this purpose. For example, clients may agree in writing or verbally to call a professional or another individual for assistance should they begin to drink or use drugs. Since clients are often embarrassed or ashamed or feel they have let others down once alcohol or drug use commences, they may fail to stop and seek help. The contract can help them acknowledge that there is a way to conclude the episode successfully. In fact, Marlatt suggests that although relapse prevention may not produce higher abstinence rates, relapses may be shorter and lead to earlier recovery (quoted in  Foxhall, 2001 ).

Effectiveness of Aftercare

Aftercare or continuing care has not been “a strong and integrated” component of drug treatment ( Gerstein & Harwood, 1990 ). Many individuals treated for alcohol problems also do not receive sufficient continuing care, either because they do not complete the treatment program they enter or due to other barriers such as inadequate insurance to cover this phase of treatment or logistical difficulties (e.g., arranging childcare) ( McKay & Hiller-Sturmöhfel (2011) .  NIAAA’s (1987)  review of the research literature “support[ed] the traditional view of the importance of aftercare services in alcoholism treatment” (p. 130). More recently,  Wexler et al. (1999)  found that of 478 inmates randomly assigned to Amity TC or a control group that did not get the in-prison TC services, those who completed the in-prison TC and voluntarily completed the TC aftercare program upon release had the lowest recidivism rate (27 percent) compared to about three-quarters of those who participated in the TC but did not complete aftercare or were in the control group.

Aftercare often seems to be comprised of mutual-help group (discussed shortly) participation, rather than formal treatment services. A study of 12 inpatient alcoholism treatment programs serving U.S. Navy personnel found that at the one-year follow-up, aftercare (primarily AA attendance) best predicted treatment outcomes ( NIAAA, 2000 ;  Trent, 1998 ). DATOS researchers also found that among drug users, attending mutual-help groups at least twice a week after treatment was associated with less relapse to cocaine use at the one-year follow up. DATOS researchers emphasize “the importance of connecting patients with some form of after-treatment self-help treatment as a critical ingredient of the treatment process in order to increase the likelihood that gains made during treatment are reinforced and sustained” ( Ethridge, Craddock, Hubbard, & Rounds-Bryant, 1999 , p. 108). A 24-month follow-up study of clients in 26 drug treatment programs in the Los Angeles area also showed that a minimum of weekly participation in Twelve-Step programs following treatment resulted in greater abstinence from illicit drugs and alcohol ( Fiorentine, 1999 ).

There may be some circularity to the argument that aftercare participation (including attendance at mutual-help group meetings) results in greater gains. Those who are doing well may be the ones predisposed to participate in aftercare programs, while those who are not doing well may shun them. However,  McKay and Hiller-Sturmöhfel (2011)  indicate that of 20 controlled continuing care studies conducted since the 1980s on alcohol or drug use disorders (most involved a cognitive behavioral approach), the later studies showed greater effectiveness, suggesting that these treatments may be improving. Those that lasted at least 12 months or made greater efforts to keep clients involved, including inclusion of significant others, also seemed to produce better results. Tailoring continuing care approaches to clients’ needs and preferences should also be a priority.

Maintenance

Maintenance is a crucial part of the treatment continuum because it lasts throughout the individual’s life. However, it generally receives the least attention. Approaches to maintenance vary, depending on the individual’s needs and preferences. Undoubtedly the most popular method of maintenance is continued use of mutual-help groups like Alcoholics Anonymous and Narcotics Anonymous (discussed at the end of this chapter). Some people drop into aftercare services or contact a professional as they feel the need. Practicing the relapse-prevention techniques learned in intensive treatment, outpatient services, or aftercare components is also important in a long-term maintenance program.

One statement that can be made about those treated for chemical dependency is that their relapse rates are high, regardless of the type of treatment they receive. Perhaps two-thirds or more of clients with alcohol problems relapse, making the treatment effectiveness literature difficult to evaluate ( NIAAA, 1987 ).  McLellan and colleagues (2000)  note that 40 to 60 percent of people with alcohol or drug problems relapse, They also note that rates of treatment noncompliance are similar for people who have asthma, diabetes, and hypertension. These are also chronic illnesses with behavioral aspects. Rather than total prevention of relapse, chemical dependency specialists have come to realize that reduced drug use and longer periods of abstinence are also indicators of success.

Studies on the efficacy of teaching relapse prevention as a maintenance strategy have yielded some positive results. Despite the difficulties in studying mutual-help groups mentioned earlier in this chapter, research on Alcoholics Anonymous as an approach to aftercare and maintenance generally suggest positive results in helping people with alcohol use disorders refrain from drinking ( Bradley, 1988 ;  Emrick, 1987 ;  Fiorentine, 1999 ).

Education and Psychoeducation

Didactic education about chemical abuse and dependency is also part of the treatment continuum. It is an essential element of almost all the components of the service system we have discussed. Whether it is education about the physiological effects of alcohol and other drugs presented to patients during their brief stay in detoxification programs or education about the effects of chemical dependency on the family presented to clients and their loved ones during intensive treatment, accurate information can address misconceptions, present the controversies in the field, and provide a foundation for rehabilitation and recovery.

Psychoeducation has become increasingly popular in the human service professions. It combines the presentation of didactic information to increase knowledge with a variety of other techniques to help clients make desired changes and to provide support. Among the methods employed are role-plays (e.g., to practice communication or assertiveness skills), structured exercises (e.g., genograms or other family exploration exercises), homework assignments (e.g., reading, charting behaviors, or keeping journals), and group discussion.

Although education or psychoeducation are part of all the components of treatment, they can also be primary services occupying their own place on the continuum of care. For example, in addition to a fine, license suspension, and any jail term, those convicted of driving while intoxicated (DWI) or driving under the influence (DUI) are usually required to attend an educational program. These programs describe the effects of alcohol and other drugs on behavior, allow participants to review the circumstances that led to their DWI or DUI arrest and consider ways to avoid such problems in the future, present the signs and symptoms of chemical abuse and dependency, and help participants consider whether they are comfortable with their current use of alcohol or other drugs. Students in DWI or DUI courses may be screened for substance use disorders and referred to treatment if indicated, but many do not meet the criteria for these diagnoses.

Education and psychoeducation may also be the primary services offered to youths apprehended by law enforcement on minor-in-possession-of-alcohol charges or other alcohol- and drug-related infractions. The juvenile courts may also require parents to attend educational sessions when their child has been involved in an alcohol- or drug-related incident. High schools, colleges, and universities have established alcohol and drug education courses for those referred for disciplinary action after illicit drug use, underage drinking, or causing disturbances or damaging property while intoxicated. These institutions are also using education and psychoeducation (and sometimes brief interventions) to help students explore the relationship between alcohol and other drug use and sexual behavior, including contracting sexually transmitted diseases, and the role that alcohol or other drug use can play in hazing and sexual assault. Despite the wide use and presumed beneficial effects of educational lectures, films, and groups, when used alone, they have received low marks in helping people with alcohol problems change their drinking behaviors ( Miller et al., 1995 ;  Miller & Wilbourne, 2002 ;  Moyers and Hester, 1999 ). Education as a tool in preventing chemical abuse and dependency is discussed at length in  Chapter 7 .

Adjunctive Services

The final component of the treatment continuum is adjunctive services (also see  Chapter 5  of this text). In addition to substance abuse or dependence, a systems or multidimensional approach requires the remediation of employment, legal, family, health, and other problems the client is experiencing. In NIDA’s large-scale DATOS study, researchers found that clients were receiving less adjunctive services (medical, psychological, family, legal, educational, and employment) than indicated in earlier research, especially medical and psychological services ( Ethridge et al., 1995 ;  Ethridge, Hubbard, Anderson, Craddock, & Flynn, 1997 ). Although vocational rehabilitation has long been an adjunct to chemical dependency treatment,  Hser and colleagues (1999)  also found that only ten percent of drug abuse clients’ job training and housing needs were met.

A referral is sufficient for some clients to avail themselves of adjunctive services. Others need additional assistance. For some, this may involve coordinating and monitoring adjunctive services for the client. The terms case management and care management are used to describe these coordination and monitoring functions. Some state, county, and local agencies have special case-management units to assist clients with multiple problems. Clients served by these units generally (1) have problems that are severe and persistent, (2) have a history of involvement with the chemical dependency or mental health service delivery systems or both, and (3) have had difficulty in utilizing available services. Monitoring can prevent crises through the early recognition of new and recurring problems (Weil et al., 1985). Most outpatient substance abuse treatment programs provide case-management services, although what constitutes case management differs widely across programs ( Alexander, Pollack, Nahra, Wells, & Lemak, 2007 ).

Case management has gained more attention from chemical dependency treatment providers, primarily for populations who have multiple and long-term needs. Case-management models have been used with various drug-abusing populations: intravenous drug users, methadone maintenance clients, HIV-positive drug users, drug-abusing pregnant women, formerly homeless women, youths, and parolees ( Ashery, 1992 ;  Siegal & Rapp, 1996 ). Many creative attempts have been made to use case management, such as the approach Levy and associates ( 1992 ,  1995 ) describe to reach out to drug abusers in a combined program of case management and peer support. In addition to its use in providing services to clients with multiple needs, private and public health insurance providers use case management to control both the services drug-abusing clients use and the costs of assisting them.

If human service professionals are to continue to support a systems, multidimensional, or biopsychosocial view of substance abuse treatment, it is necessary to demonstrate that addressing problems in addition to the substance abuse or dependence promotes better outcomes for clients.  McLellan and McKay (1998) note that clients benefit from adjunctive services when their problems are severe enough to warrant services. After studying 742 male military veterans who had received substance abuse treatment,  McLellan and colleagues (1981)  found “little relation” between the severity of the clients’ substance use and functioning in most areas of life, indicating that substance abuse treatment alone may not be sufficient to help clients address employment, housing, and other problems. These problems may require specific adjunctive interventions. DATOS supports this contention in that “client reports indicated that drug abuse counseling alone did not address their wide ranging service needs” ( Etheridge et al., 1995 , p. 9).

A large-scale study of supported work demonstration programs indicated that compared to controls, substance abusers participating in these programs had greater employment and less criminal activity, even though drug use did not differ between the two groups ( Manpower Demonstration Research Corporation, 1980 ).  Hser and colleagues (1999)  studied 171 clients and found that, in descending order, their most frequent needs were for job training, transportation, housing, and medical services. Those clients who expressed a need for a certain service and received that service improved more on that domain than clients who expressed a need but did not get the service or who did not express a need for a service. Clients whose expressed needs were met also stayed in treatment longer. Clients who asked for and received housing services and child care to attend treatment showed more improvement on drug problem severity scores, but other services were not related to improvements in drug problems.  Friedmann, Hendrickson, Gerstein, & Zhang (2004)  also conducted a study, this one using data from the National Treatment Improvement Evaluation Study, with a sample of 3,100 who needed services beyond core short- or longer-term residential services, outpatient methadone, or other outpatient services. The benefits of matching services to needs in five areas (medical, mental health, family, vocational skills, and housing) were strongest for reduced drug use among those with more needs and for those in long-term residential programs, though mental health services were not related to reduced drug use.

Fiorentine (1998)  provides a somewhat different view of adjunctive services. He studied 330 clients and found little evidence to support the idea that clients’ unresolved employment, housing, health, and other needs result in poorer treatment engagement or more drug use. He suggests that even resolution of these other problems will not likely improve drug use outcomes.

Though evidence indicates that case management may be effective in helping clients access services, it is not easy to separate the effects of case management from those of the other services the client receives ( Ridgely & Willenbring, 1992 ). A number of studies with samples of substantial size do support the use of various approaches to case management to help chemically dependent clients address their multiple needs, perhaps because they encourage clients to use more services or to make better use of those services.  Siegal and colleagues (1996)  found that military veterans with substance use disorders who received strengths-based case management had increased income and days employed.  Conrad et al. (1998)  studied residentially-based case management for homeless military veterans who were chemically dependent and found improvements in alcohol problems, employment, housing, and health. Differences between this group and a control group diminished in the year following treatment. Among substance-abusing pregnant women,  Laken and Ager (1996)  and  Laken, McComish, and Ager (1997)  found that case management along with transportation improved treatment retention.  Metja et al. (1997)  found improvements in treatment access, retention, and outcomes among intravenous drug users receiving case-management services.  Cox et al. (1998)  also found that homeless, chronic public inebriates who received case management did somewhat better with regard to drinking outcomes and living situation, compared to a control group. A study of clients in eight Philadelphia outpatient substance abuse programs who received clinical case management found improvements in alcohol use, family relations, and medical, employment, and legal statuses ( McLellan et al., 1999 ).

Platt et al. (1998)  found that “in many ways, case management is the most valuable of adjunctive services for substance abusers in treatment” (p. 1053). Individual studies do suggest beneficial effects, but a systematic review concluded that while case management can be effective in linking clients with substance use disorders to adjunctive services, the evidence is not conclusive that it produces less substance use or other beneficial outcomes ( Hesse, Vanderplasschen, Rapp, Broekaert, & Fridell, 2007 ).

More Treatment Effectiveness Issues

Some concerns about treatment effectiveness cut across treatment modalities, including length and intensity or amount of treatment, client and therapist characteristics, theoretical approaches to treatment, and costs.

Length of Stay

In general,  Gerstein and Harwood (1990)  found improvement among illicit drug users was positively related to length of stay in treatment, whether clients participate in therapeutic communities, outpatient methadone maintenance programs, or other outpatient services. Other studies support this finding. For example, DATOS researchers report that stays, or treatment thresholds, of at least three months in long-term residential treatment (including therapeutic communities) and of at least a year in outpatient methadone treatment were associated with better outcomes than were shorter stays ( Simpson, Joe, & Brown, 1997 ).  McLellan and McKay (1998)  offer two ideas as to why length of stay is positively related to better outcomes. One is that positive changes may come about gradually as treatment progresses; therefore, clients should be encouraged to remain in treatment. Given high treatment dropout rates, the other explanation is that more highly motivated clients are already disposed to remain in treatment and to have more positive outcomes; thus, motivation, rather than length of stay, may be the key to their recovery. Others suggest that length of stay for those with drug disorders may not be as clear cut an issue as once thought ( Wallace & Weeks, 2004 ).

The evidence on length of stay for clients with alcohol use disorders is equivocal. Some studies show that increased stays did not improve client outcomes, while in other studies, longer stays were associated with more positive outcomes ( NIAAA, 19871 ;  Trent, 1998 ). Two studies of note found that shorter stays in inpatient alcoholism treatment were as effective as longer stays.  Barnett and Swindle (1997)  found that 28-day programs produced only slightly better outcomes among VA patients than did 21-day programs, and  Trent (1998)  found no statistically significant differences in outcomes for active duty military personnel who received either four weeks or six weeks of treatment. However, intensive inpatient programs of even three or four weeks’ duration have become increasingly scarce in this era of health care cost containment. Perhaps more relevant in today’s world is that Project MATCH participants improved whether they received four or 12 sessions of treatment over a 12-week period ( Project MATCH Research Group, 1997a ; see  Box 6.5  on pp.  141 – 143 ).

In addition to length of stay, whether clients complete or graduate from the treatment program may also be an issue. For example, in a study of military veterans participating in an intensive outpatient substance abuse treatment program, graduates used significantly fewer psychiatric inpatient bed days one-year after program completion compared to dropouts; they were also more likely to be abstinent and less likely to have a full blown relapse or be incarcerated at 6-monthfollow-up ( Wallace & Weeks, 2004 ). The question that still begs to be answered is: How much treatment is enough for a given client?

Amount and Intensity of Services

Studies generally indicate that receiving more services promotes better treatment outcomes.  McLellan, Grissom, Brill, Durell, Metzger, and O’Brien (1993) studied four private substance abuse treatment programs—two residential and two outpatient—and found that clients fared better in “the programs that provided the most services directed at a particular treatment problem” (p. 253). They also cite evidence from earlier studies that both “quantity and range of services” are positively related to client outcomes.

Similarly, in an examination of 100 treatment studies,  Monahan and Finney (1996)  found that higher-intensity treatments (i.e., more hours of services) produced abstinence rates 15 percent higher than lower-intensity treatments. The  Project MATCH Research Group (1998b)  found that intensity may be important in outpatient treatment. Overall, clients had similar drinking outcomes regardless of which of three treatments they received. However, outpatient clients who received four sessions of motivational enhancement therapy over the 12 weeks were less likely to be abstinent or drinking nonproblematically at the end of the therapy, and they took longer to achieve abstinence or to drink without problems than those who received once-weekly sessions of either cognitive behavioral therapy or Twelve-Step facilitation therapy over the 12-week treatment period. DATOS provides a somewhat different picture.  Ethridge et al. (1999)  found that length of time in treatment was important in improving outcomes among cocaine abusers, but the amount of counseling and self-help group participation during treatment was not, suggesting that packing more services into a shorter time period may not promote better treatment outcomes. More information is needed on the combination of setting, duration, service intensity, and amount of services in promoting better treatment outcomes.

Client Characteristics

Some of the clearest evidence from alcoholism treatment effectiveness studies is that client characteristics are much more important than treatment type or setting in predicting outcome. According to  NIAAA (1990) , clients who are “married, stably employed, free of severe psychological impairments, and of higher socioeconomic status” (p. 130) are more likely to have positive outcomes, perhaps because these characteristics promote treatment compliance ( O’Brien & McLellan, 1998 ). DATOS ( NIDA, 1999 ) also indicates that an absence of psychological problems (especially antisocial personality disorder) promotes treatment retention (and by inference, better outcomes) among clients with drug problems. Having no prior legal problems or having legal pressure to stay in treatment also promoted retention. Clients’ motivation for treatment is also positively associated with treatment retention ( NIDA, 1999 ;  Project MATCH Research Group, 1998a ).

These findings also suggest that treatment success may be contingent on helping clients compensate for problems—specifically, severe psychiatric problems, marital difficulties (lack of social support), unstable employment, low income, and low motivation that may hinder treatment progress. Improvements have been made in some of these areas. For example, many communities now have programs that combine psychiatric treatment with chemical dependency treatment (see  Chapter 13  of this text). Some chemical dependency treatments incorporate family members and coach them in how to support the individual with an alcohol or drug problem. The previous section of this chapter on adjunctive treatment also provides evidence of the importance of helping clients address problems such as vocational difficulties in addition to addiction.  Chapter 5  addressed motivating clients in the precontemplation or contemplation stages into taking action to solve their problems.

We can also consider the relationship of client satisfaction to treatment outcomes. While patient satisfaction has been emphasized in the health care field, it has received little attention in substance abuse treatment. Findings have been inconsistent in the few studies that have been reported ( Zhang, Gerstein, & Friedmann, 2008 ). Zhang et al. conducted a study using structured computer assisted-interviews with a sample of nearly 5,000 individuals from 68 areas in 17 states attending publicly sponsored methadone, outpatient, and short- and long-term residential drug abuse treatment programs. They found that higher satisfaction was related to less drug use at follow-up over and above length of stay and other patient and program characteristics, though the amount of variance explained was relatively small. The authors suggest that satisfaction might be affected when patients and clinicians do not agree on the course of treatment, and they emphasize that patient satisfaction is an important component of patient-centered care.

Therapist Characteristics

Surprisingly little research has been conducted on the effects of therapist or counselor characteristics on substance abuse treatment outcomes. Research indicates that substance abuse therapists vary in their effectiveness ( Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985 ;  Najavits & Weiss, 1994 ). However, effectiveness is apparently not related to therapists’ credentials or whether they are in recovery themselves (see  Hser, 1995 ;  Najavits, Crits-Christoph, & Dierberger, 2000 ;  Project MATCH Research Group, 1998c ).

Seemingly more important in determining effectiveness is whether therapists have strong interpersonal skills and can build positive relationships with clients ( Najavits & Weiss, 1994 ). For example,  Luborsky and colleagues (1985)  reported on 77 clients randomly assigned to nine therapists and found that therapist personality, “particularly the ability to form a warm, supportive relationship” (p. 609), was a key determinant of treatment effectiveness. DATOS supports the importance of counselor/client rapport in promoting treatment success with clients who abuse cocaine or other drugs ( Broome, Simpson, & Joe, 1999 ;  Fiorentine & Hillhouse, 1999 ).  Valle (1981)  also found that clients who had alcoholism counselors with higher levels of interpersonal functioning (empathy, genuineness, concreteness, and respect) had fewer relapses. Miller and colleagues ( Miller & Baca, 1983 ;  Miller, Taylor, & West, 1980 ) found accurate empathy (see  Chapter 5 ) to be important in predicting client outcomes over a two-year period, although the association deteriorated over time. In general, clients in their study who received directive approaches (advice and feedback about their drinking and minimization of their problems) and those whose treatment was based on empathy and reflective listening fared equally well on drinking outcomes.

One therapist behavior deserved special note: “The more the therapist confronted, the more the client drank” ( Miller, Benefield, & Tonigan, 1993 , p. 455).  Fiorentine, Nakashima, and Anglin (1999)  found counselors’ empathy and helpfulness and other treatment variables more important than client characteristics in predicting clients’ treatment engagement and outcomes.  Connors and colleagues (1997)  studied therapeutic alliance—the bond between client and therapists and their agreement about the goals and tasks of treatment—among Project MATCH clients. After controlling for many other client, therapist, and treatment characteristics, alliance was significantly related to outpatient clients’ treatment outcomes but accounted for no more than 3.5 percent of the variance for any single outcome measure. The results were even more modest among aftercare clients.

Viewing the issue from the perspective of the content of treatment providers’ work, rather than their affective qualities,  Costello (1975)  reviewed 58 alcoholism treatment effectiveness studies and discovered that the staff in more effective programs made home visits to clients and reached out to collaterals. In  Luborsky et al.’s (1985)  study, in which clients were randomly assigned to therapists, therapists’ fidelity to the type of therapy they were assigned to provide was also an important factor in treatment effectiveness.

Matching clients and therapists may be another approach to improving client outcomes.  McLachlan (1974)  studied 94 alcoholics and found that those who matched their group therapist on conceptual level (interpersonal development) did better in maintaining abstinence than those who were not well matched on this characteristic. Chemical dependency studies provide insufficient information to determine whether matching clients and therapists on gender, ethnicity, age, and other factors would improve treatment outcomes but some studies have been conducted.

A retrospective study indicated that women, Latinos, and clients over age 35 were more likely to be abstinent at follow-up if they had a counselor of the same gender, and women were more likely to be abstinent if they were of the same ethnicity as their counselor ( Fiorentine & Hillhouse, 1999 ). However, ethnic and gender matches were not associated with treatment engagement. In addition, having a more empathic counselor (as rated by clients) resulted in greater engagement and abstinence and was more important than gender or ethnic congruence for all groups except Latinos, who benefited more from gender congruence.  Suarez-Morales and colleagues (2010)  note studies showing that compared to members of other ethnic groups, Hispanic clients who had a therapist of the same ethnicity tended to do better on treatment engagement, participation, and abstinence, but given the wide variation among Hispanic groups, these researchers wanted to know more about what aspects of the ethnic matching accounted for these differences. Using a sample of 16 Hispanic therapists and 235 clients randomly assigned to them for specific types of treatment, they found that matching clients and counselors on birthplace and client-counselor differences in “Hispanicism” and “Americanism” scores were not related to clients’ treatment participation or days of substance use. Counselors’ birthplace and their Hispanicism and Americanism scores were not related to clients’ treatment participation but they were related to days of substance abuse. On average, clients whose counselors were born in Latin America and had higher Americanism scores used substance on more days, while clients whose counselors had higher Hispanicism scores used substance on fewer days. Though it is unclear why the therapists’ characteristics affected substance use in this way, it was the counselors’ characteristics, rather than client’s ethnic or cultural match with their counselor, that had the greatest effect on substance use.

Theoretical Perspectives

A cornucopia of theoretical perspectives has been used to treat people with substance use disorders, including behavioral, cognitive, and psychodynamic (see, for example,  Cohen et al., 2009 ;  Miller & Wilbourne, 2002 ;  Ries, Fiellin, Miller, & Saitz, 2009 ;  Witkiewitz & Marlatt, 2011 ). In a review of just one major school of thought, cognitive-behavioral approaches (broadly defined),  Kadden (1994)  identified the following techniques of interest in treating people with alcohol problems: coping skills training, relapse prevention, behavioral marital and family therapy, community reinforcement, behavioral self-control training, aversion therapy, cue exposure therapy, and motivational interviewing.

According to  NIAAA (1987) , “In contrast to classical, dynamic, insight-oriented psychotherapy, alcoholism counseling is directive, supportive, reality centered, focused on the present, short term, and oriented toward real world behavioral changes” (p. 127). Much of the same can be said for the treatment of illicit drug abusers. Traditional, insight-oriented psychotherapy has historically been viewed as ineffective in helping clients terminate drug use because psychotherapists often failed to encourage abstinence, and treatment often centered on anxiety-arousing topics, which may have prompted patients to drink or use drugs ( Rounsaville, Carroll, & Back, 2009 ; also see  Rawson, 1995 ). In addition, exploration of psychological, often unconscious, conflicts did little to help patients understand their addiction because to date, scientists have not discovered the causes of chemical dependency.  Miller and Wilbourne (2002)  found most psychotherapy ineffective in treating alcohol problems, though client-centered therapy (based on Carl  Rogers’s [1951]  work) did show positive results in some studies. Nonetheless, in one study using random assignment of 260 male court referrals, those given rational behavior therapy or insight-oriented treatment did better in reducing drinking than those referred to an AA-focused discussion group ( Brandsma, Maultsby, & Welsh, 1980 ). The insight group had the fewest legal problems, and those in all groups did better than controls that pursued their own treatment arrangements. Perhaps insight-oriented psychotherapy or other theoretical perspectives should not be summarily dismissed. At a minimum, people with alcohol and drug problems who wish to address additional concerns following sobriety may benefit from a variety of treatment perspectives. Though there may be a preference for cognitive-behavioral therapies in treating substance use disorders, we continue to agree with  Luborsky and colleagues (1985)  that there is really little evidence to suggest that some theoretical perspectives are substantially better than others.

Today, the word psychotherapy is used broadly to encompass many types of treatment. It is therefore important that researchers carefully describe the treatment that they are studying. One effort in this regard is the use of treatments that have been specified in manual form along with supervision and review of tapes of treatment sessions in order to ensure that therapists are maintaining fidelity to the treatment under investigation (see  Box 6.5  on pp.  141 – 143 ).

Substantial work has been done to match clients with treatments based on theoretical perspectives hypothesized to be most likely to meet their needs. Although Project MATCH researchers (again, see  Box 6.5  on pp.  141 – 143 ) found few benefits of matching clients to treatments based on hypothesized fits between client characteristics and theoretical treatment perspectives, this does not mean that client/treatment matching studies should be abandoned. For example,  O’Malley and associates (1992)  found that supportive treatment produced more abstinent patients than coping skills treatment; however, among patients who initiated drinking, those who received coping skills treatment were least likely to relapse.

Aversion therapy or counterconditiong is another theoretical perspective.  Cannon and associates (1988)  report that one corporation “discontinued the use of aversion therapy in all 21 of its hospitals to improve its ability to recruit patients” (p. 205).  Frawley and Howard (2009) , however, call aversion therapy “a powerful tool in the treatment of alcohol and drug addiction. Its goal is to reduce or eliminate the ‘hedonic memory’ or craving for a drug and to simultaneously develop a distaste and avoidance response to the substance” (p. 843). When used, aversion therapy is generally combined with other chemical dependency treatment services. (For a review of aversion procedures using nausea producing drugs or mild electrical stimulation to the forearm, safety contraindications, and criticisms, see  Frawley [1998] ). Nausea and electrical aversion have been tried in alcohol, marijuana, and cocaine/amphetamine dependence treatment. Several medical panels and scientific boards support these aversion treatments (Frawley & Howard).

A small number of studies suggest the effectiveness of apneic aversion (in which breathing is briefly ceased), nausea aversion, and covert sensitization for people with alcohol use disorders ( Miller & Wilbourne, 2002 ), though  Elkins (1975)  notes serious ethical concerns about apneic aversion, which can be traumatic. More studies have been conducted on electrical aversion, but the evidence supporting it seems relatively weak (Miller & Wilbourne). “Covert sensitization employs imagery of unpleasant stimuli to elicit the aversive responses needed to accomplish . . . counter conditioning” (p.  144 ), and  Shorkey (1993)  notes that it is the only aversive conditioning technique that can practically be employed by most human service professionals.

It is probably accurate to say that treatment providers bring diverse theoretical perspectives to their work. Many have developed theoretical perspectives of their own that are a combination of approaches. In many cases, treatment providers try several approaches in an attempt to find one that will work with a particular client.

The Mesa Grande project is an analysis of the research evidence for treatment approaches for alcohol use disorders by William R. Miller and colleagues ( Miller et al., 1995 ; Miller, Wilbourne, & Hettema, 2003;  Miller & Wilbourne, 2002 ). In 2003, Miller and his colleagues wrote that “the negative correlation between scientific evidence and treatment-as-usual remains striking, and could hardly be larger if one intentionally constructed treatment programs from those with the least evidence of efficacy” (p.  41 ). With more emphasis on evidence-based practice, this may be changing, though some significant gaps between research and practice remain ( Herbeck, Hser, & Teruya, 2008 ). Meta-analyses based on statistical pooling of studies are another tool to help determine what works in the alcohol and drug treatment fields (for a discussion of the these approaches, see  Heather, 2007 ). The Cochrane Collaboration in particular now supports a number of these meta-analyses. 2

To bridge the gap between evidence from the treatment effectiveness literature and the treatment service programs provide, in 1999, the National Institute on Drug Abuse established the Clinical Trials Network so that researchers and community-based service providers could “cooperatively develop, validate, refine, and deliver new treatment options to patients in community-level clinical practice.” In addition, the Center for Substance Abuse Treatment, part of SAMHSA, operates 13 regional Addiction Technology Transfer Centers (ATTCs) and a national ATTC office, which work to increase practitioners’ “access to state-of-the art research and education.”

Cost Effectiveness of Treatment

Though national studies are limited, research continues to demonstrate that treating alcohol and drug problems produces favorable cost/benefit ratios ( Cartwright, 2000 ;  Center for Substance Abuse Treatment, 2009 ). For example, the widely cited California Drug and Alcohol Treatment Assessment (Cal DATA) found a return of $7 for each dollar invested in treatment ( Gerstein et al., 1994 ). Most of the savings were due to reduced crime. A subsequent study, the California Treatment Outcome Project (Cal TOP), which improved on the Cal DATA methodology, also found a return ratio of more than 7:1 ( Ettner et al., 2006 ). The ratio was based on pre- and post-treatment admission data that included health and mental health care, criminal activity, and earnings.

More information is needed on the costs and benefits of particular treatments for substance-use disorders. In early work on this issue,  Holder and colleagues (1991)  found that generally, more expensive treatments appeared to be less effective than lower costs treatments, but a subsequent study found “no relationship between cost and effectiveness” ( Finney & Monahan, 1996 ). Work continues on estimating the costs of various treatment modalities ( French, Popovici, & Tapsell, 2008 ). To maximize scarce resources, research is needed on matching clients with the treatments that are most effective for them and the least costly.

Nontraditional Approaches

Nontraditional treatments, some of which are referred to as natural, complementary, or alternative therapies medicine for substance use disorders (see  Boucher, Kiresuk, & Trachtenberg, 1998 ;  Dean, 2005 ), include many more approaches than we are able to discuss here. Among them are the use of nutrition, vitamins, and herbal remedies ( Lu, Liu, Zhu, Shi, Liu, Ling, & Kosten, 2009 ); hypnosis and meditation in many forms (Boucher et al.,  O’Connell & Alexander, 1994 ), including recent scholarly attention to the use of mindfulness-based therapies ( Marcus & Zgierska, 2009 ;  Zgierska et al., 2009 ); the application of religion, spirituality, and prayer (Boucher et al.;  Galanter, 2009b ;  Muffler, Langrod, Richardson, & Ruiz, 1997 ); stress-reduction and relaxation techniques ( Shorkey, 1993 ); biofeedback or alpha-theta brainwave training ( Peniston & Kulkosky, 1989 ,  1992 ); Internet-based screening tools, interventions, and support groups( Cunningham, Kypri, & McCambridge (2011) ;expert systems consisting of computer feedback reports and self-help manuals gauged to the stage of change or treatment ( Prochaska et al., 2001 ); smartphones that allow patients to check in and enter information on how they are doing and request emergency or other assistance and that provide reminders to take medications and keep appointments, motivational or inspirational messages and stories, locations of mutual-help group meetings, and other features (Gustafson et al., 2001); and node-link mapping, in which a visual or pictorial display is created of client problems or issues and potential solutions ( Joe, Dansereau, Pitre, & Simpson, 1997 ). Readers may be interested in exploring any or all of these approaches. The discussion of nontraditional and alternative treatments that follows focuses on some of those most commonly discussed in the addiction field, including controlled or moderated drinking, acupuncture, and contingency management (incentives to promote abstinence or reduce drug use).

Controlled or Moderated Drinking

The terms controlled drinking and moderated drinking have been used to describe both the desire of some alcoholics to drink in a socially acceptable manner and the treatment goal of teaching alcoholics to drink in a socially acceptable manner. The idea of teaching alcoholics to drink in a controlled manner has been met with more than spirited debate since the goal for clients in traditional treatment programs is usually abstinence.

Many individuals reject total abstinence, and apparently some people who have drunk in an abusive or alcoholic manner go on to adopt more moderate drinking practices ( Armor, Polich, & Stambul, 1978 ;  Connors, 1993b ;  Pattison, Sobell, & Sobell, 1977 ). Some do this following treatment or after minimal contact with detoxification units or information or referral centers or without any assistance from professionals or mutual-help groups ( Humphreys, Moos, & Finney, 1995 ;  Sobell, Cunningham, & Sobell, 1996 ;  Witkiewitz & Marlatt, 2011 ). In his classic longitudinal study of alcoholic men,  Vaillant (1983) , who supports the disease theory of alcoholism, found that a substantial number returned to non-problematic social drinking without treatment. If it were possible to determine which individuals could achieve abstinence or moderate drinking without professional assistance “limited treatment resources could be more usefully directed to persons who may need them to recover” ( Humphreys et al., 1995 , p. 439).

Our discussion of controlled or moderated use is limited to alcohol, since the controlled use controversy has centered on this substance. However, some people apparently use drugs such as marijuana and even heroin and other narcotics (called “chipping”) in a controlled manner throughout their lives ( Callahan & Pecsok, 1988 ).

The controversy over controlled drinking gained momentum in the 1970s when Rand Corporation researchers published a NIAAA-funded study titled Alcoholism and Treatment ( Armor et al., 1978 ; also see Ray & Ksir, 1987). Similar to reports by  Pattison and colleagues (1977) , they found that 18 months following contact with an alcoholism treatment program, a number of the male patients in the study sample reported that they were drinking in a so-called controlled (nonproblematic) fashion or were alternating between drinking and abstention, even though they had been treated in traditional, abstinence-oriented programs. A second follow-up conducted four years after treatment found that 46 percent were in remission (i.e., 28 percent were currently abstinent and 18 percent were “drinking without problems”; the remaining 54 percent were drinking “with problems”) ( Polich, Armor, & Braiker, 1981 ). As with many other research studies, this one was criticized on methodological grounds. More noteworthy was the controversy generated because the study challenged the notion that abstinence is the only viable goal for people with alcohol dependence.

The work of Mark and Linda Sobell (1973a, b)added to the consternation. The Sobells used individualized behavior therapy in an effort to teach individuals who had lost control of their drinking to drink in a controlled manner while comparing them with similar individuals who were treated with a goal of abstinence. The individualized behavior therapy used to teach patients controlled drinking included identification and practice of alternative responses to excessive drinking, electric shocks, education, comparison of videotapes of themselves when drunk and sober, and other procedures. (Another technique that has been used in controlled drinking is teaching clients to discriminate their blood-alcohol levels.) After two years, the  Sobells (1976)  concluded from treatment outcomes that some alcoholics could successfully pursue controlled drinking if they were treated by a professional skilled in using this approach. They cautioned that this did not mean that all or a majority of alcoholics would be appropriate for this treatment.

Several attacks of this work followed. In an effort to discern what later happened to the original 20 alcoholics taught controlled drinking,  Pendery, Maltzman, and West (1982)  conducted a 10-year follow-up. They found that only 1 person had continued to engage successfully in controlled drinking, that 8 had continued to drink problematically, that 6 had become abstinent, that 4 had died from alcoholism, and that 1 was missing. How these 20 alcoholics would have fared if treated in an abstinence-oriented program from the outset cannot be determined, and it is not known how they fared over the long run in relation to the comparison group.

After reviewing research on the subject,  Connors (1993b)  concluded that “in fact, moderate drinking interventions with low to moderate severity alcohol abusers may be the treatment of choice” (p.  125 ). He also noted that good outcomes are less likely with “severely dependent alcoholics” (p. 125), but the hypothesis that achieving moderation is “inversely related to severity of alcohol dependence” has met with mixed results in the research (p. 129). Note the word moderation rather than controlled drinking in this paragraph, which may be used to avoid the negative connotations associated with the controlled drinking controversy. In a more recent study,  Dawson and colleagues (2005)  found that about one-quarter of people with prior year or previous alcohol dependence ever received treatment, and of all those classified with past dependence, 25 percent were still dependent in the past year, 27 percent were in partial remission, 12 percent had no current symptoms but their drinking pattern put them at risk of relapsing, 18 percent were low-risk drinkers, and 18 percent were abstainers.

NIAAA (2010)  advises those who have an alcohol use disorder to abstain, but it also recognizes that some people would prefer to cut down on their drinking. For those who wish to cut down, NIAAA has a list of suggestions such as listing reasons why one wants to change, setting goals, keeping track of the number of drinks consumed, and avoiding triggers that may result in excessive drinking.

There is considerable interest in the issue of controlled drinking in other countries. In a study of 103 alcohol-dependent patients admitted to an abstinence-based program in Germany, 43 percent reportedly remained abstinent throughout the 36-month follow-up period (Bottlender, Spanagel, & Soyka, 2007). Of the remainder, only four seemed to be able to practice controlled drinking, with the authors concluding that controlled drinking cannot be recommended to those who are alcohol dependent.

Surveys of alcoholism treatment providers in the United States and Canada indicate lower acceptance of moderated drinking as a viable treatment goal than in countries such as Britain, Norway, and Australia ( Klingemann & Rosenberg, 2009 ;  Rosenberg & Melville, 2005 ). In a Swiss study, controlled drinking was reportedly well accepted, but more so in outpatient than inpatient programs (Klingemann & Rosenberg). Controlled drinking was also more acceptable as an intermediate rather than final treatment goal and generally for those with less severe drinking problems and more social stability. The study’s authors believe that acceptance of controlled drinking is in keeping with a trend in Switzerland toward consumer-oriented services, which may encourage more people to participate in treatment.

Interest in moderation led  Kishline 1996a ,  b  to develop a self-help program called Moderation Management, based on the ideas that drinking problems fall along a continuum rather than being an all-or-nothing phenomenon and that “brief behavioral self-management approaches” can help people control their behavior. Kishline acknowledged that moderation is not for everyone and that some people may need to pursue the goal of abstinence. According to various accounts, in 2000, Kishline decided to pursue a goal of abstinence for herself ( Anderson, 2008 ). However, she was subsequently involved in a drunk driving accident that took two lives, and she pleaded guilty to vehicular homicide. The Moderation Management program continues to operate as do other programs aimed at helping people drink moderately.

Acupuncture

Acupuncture has been used to treat many conditions, including alcohol and drug problems ( Jordan, 2006 ). In theory, acupuncture, an ancient Chinese approach to treating medical and psychological problems with the use of needles, is said to work in the following way:

Energy (Chi) from oxygen and food flows through the organs and body where it is transformed and distributed. The acupuncturist assesses (through symptoms, physical examination and pulse diagnosis) the homeostasis of this energy and intervenes with treatment if it is out of balance. ( Worner, Zeller, Schwarz, Zwas, & Lyon, 1992 , p. 172)

Acupuncture may promote the production of beta-endorphins or other naturally occurring substances in the body, but the precise mechanisms through which it might work are not known ( Brumbaugh, 1993 ).

Acupuncture has been used to treat those with alcohol, opiate, and cocaine disorders. The procedure has been used since the mid-1970s at Lincoln Hospital’s Substance Abuse Division in New York. The criminal justice system, such as the drug court program in Dade County (Miami), Florida, has made extensive use of acupuncture. The National Acupuncture Detoxification Association (NADA) offers suggested protocols for the use of acupuncture as an adjunctive treatment for addictions and provides training in the techniques. NADA reports that “more than 1,500 clinical sites in the U.S., Europe, Australia and the Caribbean currently utilize these protocols. 3 ” The  World Health Organization (2003)  classifies alcohol dependence and detoxification and opium, heroin, and cocaine dependence “conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed.”

Alcohol Dependence

Bullock and colleagues 1987 ,  1989  found positive results in two controlled, single-blind studies using acupuncture with severe, chronic alcoholics. The experimental groups received acupuncture at points thought to be specific for substance abuse treatment, whereas the controls received it at nonspecific points. The subjects in these studies were given a place to live during the treatment, but other than Alcoholics Anonymous, no traditional chemical dependency treatment was provided. Control subjects were less likely to complete treatment, reported a greater desire to drink, and had significantly more episodes of drinking and detoxification admissions than experimental subjects.

Several subsequent studies have been less positive.  Worner and associates (1992)  found no difference in treatment or control subjects, all of whom were alcoholics of lower socioeconomic status, with respect to attendance at AA or treatment, treatment completion, detox admissions, or relapses. Subjects were randomly assigned to one of three groups: point-specific acupuncture along with standard, outpatient alcoholism treatment; needleless or sham acupuncture with standard treatment; or standard treatment only. They found that many individuals were unwilling to receive acupuncture treatment. Worner reported a much higher dropout rate from the point-specific acupuncture treatment group than did Bullock. In another study,  Bullock et al. (2002)  randomly assigned 503 clients in a Minnesota Model-type alcoholism inpatient treatment program to receive specific acupuncture, nonspecific acupuncture, symptom-based acupuncture, or no acupuncture. In general, the acupuncture conditions did not produce greater reductions in drinking than the inpatient treatment program alone. In a systematic review of 11 studies,  Cho and Whang (2009)  concluded that “results . . . were equivocal, and the poor methodological quality . . . do not allow any conclusion about the efficacy of acupuncture for treatment of alcohol dependence” (p. 1305).

Opiate Dependence

Interest in the use of acupuncture to treat drug addicts continues, and researchers have worked to find better ways of offering placebo acupuncture treatments in blind studies because needles placed within a certain area of the ear may produce results, even if thought to be in nonspecific points ( Avants, Margolin, Chang, Kosten, & Birch, 1995 ). In a recent pilot study, researchers found positive results from using transcutaneous electric acupoint stimulation (TEAS) for opiate detoxification ( Meade, Lukas, McDonald, Fitzmaurice, Eldridge, Merrill, & Weiss, 2010 ). However, in a study of the use of auricular acupuncture as an adjunct to standard opiate detoxification,  Bearn and colleagues (2009)  found no effects on withdrawal severity or craving. In one meta-analysis of acupuncture combined with opioid agonists for opioid detoxification, the researchers found evidence of reduced withdrawal symptoms on some days of the detoxification period but not in 6-month relapse rates ( Liu, Shi, Epstein, Bao, & Lu, 2009 ). A systematic review of clinical trials of acupuncture treatment for opiate addiction also found no benefit of acupuncture over control treatment conditions ( Jordan, 2006 ).

Cocaine Dependence

Among the acupuncture studies that have been conducted are two concurrent studies with cocaine abusers by  Bullock and associates (1999) . In Study 1, 236 residential clients were randomly assigned to true acupuncture at three ear points, sham acupuncture, or conventional treatment only. In Study 2, 202 day-treatment clients received true acupuncture at five sites for either 8, 16, or 28 sessions. In total,37 percent of the clients completed the studies. There were no treatment differences between experimental and control participants in the two studies with regard to craving or functional outcomes (physical and social functioning, emotional well-being, etc.). There were also no differences in the percentage of clients with positive urine screens in Study 2. But in Study 1, the conventional treatment-only group had fewer positive screens than the true and sham acupuncture groups. In a study with a strong research design,  Margolin and colleagues (2002)  randomly assigned 620 cocaine-dependent individuals (one-third also used opiates) from six cities and six treatment sites (three hospital clinics and three methadone maintenance programs) to either NADA protocol auricular acupuncture or one of two control conditions—needle-insertion or relaxation techniques. Participants were followed for six months. Retention rates for all groups were the same. In general, participants reduced their cocaine use but the reductions did not differ by treatment condition. Counseling sessions were not well attended by any group. It seems that “acupuncture cannot yet be considered an effective adjunct to existing drug treatment programs for cocaine, or other stimulants” ( Lu et al., 2009 , p. 7).

Contingency Management

The principles of operant conditioning or reinforcement provide a useful framework for understanding both addiction and recovery ( Higgins et al., 1998 ;  Higgins, Silverman, & Heil, 2008 ). Many clients are threatened with negative sanctions (e.g., jail time) for failure to attend treatment and to stay clean and sober; however, positive reinforcers or incentives rather than negative reinforcers may be more useful in treating substance abusers ( Higgins et al., 1994 ). For example, evidence indicates that offering take-home methadone doses to clients with drug-free urine tests increases abstinence from cocaine ( Stitzer, Iguchi, & Felch, 1992 ).

One form of contingency management, material incentives, has been used as an adjunct to other forms of treatment (e.g., the Community Reinforcement Approach) to encourage patients to cease illicit drug use (see for example,  Higgins et al., 2007 ;  Silverman et al., 1996 ). Rather than cash payments, vouchers or similar approaches are used in which methadone maintenance clients or cocaine abusers who produce cocaine-free urine specimens earn points or dollar values that can be applied to the purchase of items that might enhance the clients’ treatment goals or quality of life (e.g., household, educational, or recreational items), contingent on the approval of a staff member. The value of the reward or vouchers often increases over time. In continuing study of the use of voucher-based incentives,  Higgins et al. (2007)  compared groups that could earn vouchers worth either a maximum of $1,995 or $499 over a 12-week period for producing cocaine-free urine specimens. The group that could earn more stayed in treatment longer and was more likely to produce continuous cocaine-free specimens.

A problem with using these techniques in practice is that the funds to provide cash or vouchers are not readily available. Some may ask whether the public should bear the costs of paying for such incentives. The benefits to the community, however, in reduced medical, social, and criminal justice spending from helping clients remain drug free may be worth the financial investment ( Higgins et al., 1994 ). To reduce costs, a lottery-type procedure has been used in which clients who meet target goals draw slips of paper from a fishbowl; some slips indicate prizes of varying levels while others contain words of praise but have no monetary value ( Petry, Alessi, Marx, Austin, & Tardif, 2005 ). Though Petry et al. demonstrated the effectiveness of the technique, the size of vouchers or other monetary incentives seems to be related to their effectiveness in promoting drug abstinence ( Lussier, Heil, Mongeon, Badger, & Higgins, 2006 ). Lussier et al.’s meta-analysis also found that more immediate rewards produced better abstinence results, and that, in general, studies of vouchers or other monetary incentives to increase clinic attendance or medication compliance produced positive results.

Other forms of contingency management are also being utilized. For example, Kentucky residents who gave up tobacco for one month could enter a lottery to win prizes. They had to select a nontobacco-using partner to serve as a witness, and counseling, a hotline, and website were available to assist them.

Mutual- and Self-Help Programs

Since the founding of the Washingtonian Societies in the mid 1800s, individuals have banded together to address their drinking problems in mutual-support groups ( White, 1998 ). Today, Alcoholics Anonymous and other mutual-help groups continue to be an important component of the system of care for alcoholics and addicts. They are not part of the continuum of services provided by professionals. Instead, they are composed of volunteers who both “work the program” and maintain these often loosely structured organizations. Members usually take turns chairing the meetings or acting in other capacities. Today, meetings of many mutual-help groups can be attended via the Internet as well as in face-to-face encounters.

Alcoholics Anonymous

The best-known mutual-help group is Alcoholics Anonymous (AA). AA has been described as everything from a form of psychotherapy ( Brandsma & Pattison, 1985 ;  Kanas, 1982 ;  Zimberg, 1982 ) to having an “antipsychotherapy attitude” ( Doroff, 1977 ). It has also been described in systems terms as “a model for synthesizing biomedical, psychosocial, and environmental approaches to arresting alcoholism and achieving what AA members term ‘contented sobriety’” ( Bradley, 1988 ).

Alcoholics Anonymous began in 1935, well before most health and human service professionals took a serious interest in assisting alcoholics. AA’s founders were two men, a physician and a stockbroker, who shared with each other their problems with alcohol and supported each other in maintaining sobriety. Alcoholics Anonymous estimates that it now has nearly 116,000 groups and approximately 2.1 million members ( AA, 2010 ). Groups meet throughout the United States and many other countries. A directory is available to help members locate meetings, and virtually every phone book in the United States as well as the Internet lists a local number for the organization. Local groups operate rather independently, although the General Service Office, located in New York City, provides kits to assist in starting groups and offers a great deal of literature addressed to recovering persons, their friends and family members, and the various professionals who help alcoholics.

AA is referred to as a fellowship. More than a series of meetings, it is a program for the recovering alcoholic to “work” on a daily basis. The program is based on Twelve Steps (see  Box 6.6 ) that refer to the individual’s powerlessness over alcohol, the need to recognize one’s shortcomings and to make amends, and reliance on a higher power. Many other mutual-help groups for chemically dependent individuals, such as Narcotics Anonymous, and a wide variety of other groups concerned about problems such as compulsive overeating, gambling, and sexual behavior, have adapted the AA approach. Another important aspect of AA is its Twelve Traditions, recognizing the group’s concerns about anonymity, not taking stands on outside issues, and so forth.

BOX 6.6 The Twelve Steps of Alcoholics Anonymous

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Source: The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (“AAWS”). Permission to reprint the Twelve Steps does not mean that AAWS has reviewed or approved the contents of this publication, or that AAWS necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise.

Some people with drinking problems do not seek professional assistance and instead rely on AA to help guide them through recovery. Others use a combination of professional assistance and mutual-help groups. The mutual-help movement does not appeal to all recovering individuals. Some professionals question its utility, believing that it is best reserved for certain types of individuals. However, it is probably accurate to say that most human service professionals concerned about chemical dependency encourage their clients to attend meetings in order to determine if participation is of help to them.

The only requirement for AA membership is a desire to stop drinking. There are no application forms or other requirements for participation, and there are no membership dues or fees. The groups are supported by members’ contributions. Since anonymity is stressed, members generally use only first names at meetings, and members are reminded to “leave what they hear at the meeting” so as not to violate the confidences of others.

A mainstay of AA is its meetings, which are usually about one hour long. In large cities, meetings are often conducted around the clock every day of the week. Individuals who come to meetings intoxicated are usually allowed to remain unless they cause disruption or appear to need immediate medical attention. Some cities have AA clubs where members can drop in whenever they wish.

When AA began, only a few women ventured into the meetings. Today, women are 35 percent of members ( AA, 2010 ). Some AA groups are designated for women only or men only. Other groups are for young people, although anyone young at heart is usually permitted to attend. Some groups are for members of particular ethnic groups, with meetings in the United States sometimes conducted in these members’ native languages (see  Chapter 11 ). Various ethnic groups in the United States and other countries have also adapted the principles and format of AA according to their beliefs and customs. Gays and lesbians (see  Chapter 12 ), members of particular professions, and nonsmokers have also organized groups. Sometimes the composition of the group is defined by the location where the meeting is held—an affluent residential neighborhood, the deteriorating downtown section of a city, or a prison.

The Twelve Steps include references to God, but AA describes itself as a spiritual rather than a religious program ( AA, 1952 ). God is considered a “higher power” defined according to individual preference. For some, this higher power is God in the traditional sense of organized religion; for others, it may be the AA group or virtually any other spiritual or physical entity. Religious aspects of meetings seem stronger in some groups than in others, but some atheists and agnostics have successfully recovered through the program ( AA, 1952 ).

Groups seem to develop their own “personalities,” depending on their membership. Professionals often encourage newcomers to visit several different groups and to attend meetings where they feel most comfortable. Newcomers are also encouraged to attend “90 meetings in 90 days” in order to break old patterns, to become fully immersed in the program, and to not give up too quickly.

The structure of AA meetings is generally consistent in that they begin and end with readings from the book Alcoholics Anonymous ( AA, 2001 ) and prayers, but there are different types of meetings. A speaker’s meeting is devoted to testimonials by a member or members from the local community or who are invited from out of town. Members sometimes call these talks “drunkalogues.” Each speaker tells his or her “story,” usually beginning with the circumstances surrounding his or her use and abuse of alcohol and development of alcoholism. Stories often refer to negative consequences the individual experienced while drinking and how he or she was able to recover, including his or her introduction to and use of AA. The stories assist members, especially new members, in realizing that it is possible to recover, no matter how bad one’s problems. They are also cathartic for the storytellers. Birthday meetings, at which members celebrate each year of their sobriety, are often combined with speakers’ meetings.

Another format is discussion meetings. The chairperson may offer a topic for discussion (such as guilt, resentments, loneliness, or intimacy) or ask members to suggest a topic. Members may volunteer comments on their personal experiences (rather than give advice to others). The chairperson may proceed in round-robin fashion depending on the number in attendance. Members who do not wish to speak are usually not pressured to do so and may simply say “I pass” when their turn comes. Thus, AA differs from group therapy and other forms of group treatment in which members are expected to verbalize their thoughts and interact with each other during sessions.

At step meetings, the chairperson leads a discussion on one of the Twelve Steps. Members comment on points that helped them work the step or the problems they are encountering in working that step. There is no one way or even recommended ways to work each step. Members offer their thoughts, but each person is free to work the step in a manner suitable to him or her. The book Alcoholics Anonymous ( AA, 2001 ), referred to as the Big Book, recounts the history of AA and contains the stories of various members. Big Book meetings focus on discussion of passages from the book.

Tokens are among the symbols used in AA meetings. For example, chips of different colors may be given to those embarking on sobriety (called a “desire” chip) and after one, two, three, and six months of continuous sobriety to recognize the progress the individual has made. At birthday meetings, members with one or more years of continuous sobriety are presented with a special memento, such as a silver dollar with a hole drilled in it to commemorate each year of sobriety.

Slogans for living, such as “One day at a time” and “Live and let live,” are frequently heard at AA and are often displayed on meeting room walls. Meetings generally close with everyone saying “Keep coming back; it works.”

AA conventions are held around the United States, and local groups often sponsor social and recreational activities such as dances and family picnics to provide an atmosphere where members can enjoy themselves without exposure to alcohol. For some recovering alcoholics, AA is the focus of their lives. Some criticize this as a dependence on AA or an inability to lead a normal life; others call it an individual choice. There are no rules telling a member how often to attend meetings. Some members continue to attend frequently; others attend less frequently as their sober time increases. In the early stages of sobriety, failing to attend meetings is often considered a “red flag” or a precursor to a “slip” (a lapse or relapse).

Sponsorship is another aspect of the AA program. A newcomer may ask a member to serve as his or her sponsor, and many members utilize one or more sponsors throughout their recovery. A sponsor has usually been an AA member for some time and has achieved a substantial period of sobriety, but there are no requirements to serve in this capacity. Newcomers are encouraged to select sponsors whom they feel have “solid sobriety” and with whom they feel comfortable discussing their recovery. They may also be encouraged to select a sponsor of the same gender to avoid confusing issues of recovery and sexual intimacy, although this issue is obviously different for gay men, lesbians, and bisexual individuals in recovery. The individual who is asked to be a sponsor is free to accept or decline. Sponsors can be a valuable resource, especially when they are readily available to provide support and encouragement. This is particularly important when members experience a crisis, such as a strong desire to drink, or when they want help “working” aspects of the AA program.

Why are people attracted to AA? Perhaps it is the camaraderie—that other members have been there, know the ups and downs of trying to stay sober, and are engaged in the recovery process. The fellowship of AA is a strong one. In fact, one study suggests that fellowship may be a much more important motivator to attend than spirituality ( Nealon-Woods, Ferrari, & Jason, 1995 ). Visitors and newcomers are often struck by the way members introduce themselves and are acknowledged by fellow members. When members speak at the meetings, they usually begin by saying “I’m so-and-so, and I’m an alcoholic,” to which the group responds in chorus “Hi, so-and-so!” Members and visitors are impressed with the unconditional acceptance of the alcoholic. Visitors sometimes remark that the interaction between members was so positive, they wished they were alcoholics! On the other hand, visitors and newcomers may be concerned about some of the behavior at meetings. For example, members may come and go as they wish during meetings, which can seem rude or disruptive. Or they may share their deepest thoughts and feelings but not receive a direct response, which can seem uncaring or disrespectful. Since AA is not group therapy, this behavior is not unusual; in fact, “cross talk” is discouraged.

AA groups have “closed” and “open” meetings. Closed meetings are only for those who consider themselves alcoholics. These meetings provide greater assurance to alcoholics that they are among those who share a common problem and that their anonymity will be protected. Open meetings also serve an important purpose: They allow professionals, family members and friends, those who think they might have a problem, and others to learn more about mutual-help groups, the problems they address, and the people they help. They are an important resource for every community. Anyone considering a career working with people who have alcohol and drug problems should become familiar with these meetings.

Research and Mutual-Help Groups

Alcoholics Anonymous has been touted as having helped more people recover from alcoholism than any other program ( Baekeland, 1977 ;  Sheeren, 1988 ). Some call this aggrandizement “an ill-considered hyperbole” (Baekeland). Others warn that even questioning AA’s effectiveness might cause “surprise, annoyance, anger, exasperation, shock, or perhaps even rage” ( Glaser & Ogborne, 1982 ; also see  Trimpey, 2003 ). This may be less so today, since clinicians are operating in an age of evidence-based practice, but conducting randomized controlled trials of AA and similar groups remains virtually impossible despite their unique approach and large following. This is due to the voluntary nature of the groups, concern for members’ anonymity, and difficulties in establishing fidelity to the model due to variation from group to group.

Descriptive studies of AA include periodic membership surveys of the organization as well as efforts to identify those most likely to affiliate with AA. A review of studies found that characteristics predictive of AA affiliation are greater use of external supports (i.e., reliance on others) for coping, greater loss of control drinking, more daily alcohol consumption, greater physical dependence, and greater anxiety about drinking ( Emrick, Tonigan, Montgomery, & Little, 1993 ). To this list,  McCrady (1998)  added greater concern about drinking, stronger commitment to abstinence, less spousal support, and a stronger need to find meaning in life. Nonetheless, it is difficult to predict who will or will not be attracted to AA, and  Tonigan, Toscova, and Miller (1996)  “argue against efforts to develop omnibus AA profiles” because AA groups are so diverse (p. 69).  Emrick’s (1987)  conclusion remains useful:

Until specific affiliation characteristics are identified, prudence suggests viewing all alcoholic patients in conventional alcoholism treatment as possible members of AA, while at the same time recognizing that many alcohol-dependent patients recover from their alcohol problems without ever joining the organization. (p. 418)

After noting selection biases in some studies (mainly subjects mandated to attend), one systematic review of controlled studies found that “attending conventional AA meetings was worse than no treatment or alternative treatment” ( Kownacki & Shadish, 1999 ), while a more recent review concluded that “no experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] approaches for reducing alcohol dependence or problems” ( Ferri, Amato, & Davoli, 2006 ). Despite other significant methodological problems such as self-selected and convenience samples, a number of individual studies over the last few decades suggest positive benefits from AA, primarily abstinence or reduced drinking, for those who do affiliate (see, for example,  Vaillant [1983] ; also see  Miller and Hester [1980] ,  Emrick [1987] ,  Walsh et al. [1991] ) as well as cost effectiveness ( Kelly & Keterian, 2011 ).

Individual studies also give credence to the hypothesis that AA promotes post-treatment abstinence (see, for example,  Corrigan, 1980 ;  Cross, Morgan, Mooney, Martin, & Rafter, 1990 ;  Pettinati et al., 1982 ). In one of the more recent studies, which included 416 men and women who had previously not received treatment for alcohol problems,  Moos and Moos (2006)  found that those who participated in treatment for 27 weeks or more or in AA for 27 weeks or more during the first year after initiating participation had better outcomes than those who did not participate in either. Those who continued in AA also had better 16-year outcomes while those who received additional treatment did not experience better outcomes.

Additional research might help to determine who affiliates with AA and how, who benefits most from AA involvement, and the mechanisms of these groups that produce change. For example,  Montgomery, Miller, and Tonigan (1995)  suggest it is a greater degree of involvement, rather than attendance alone that promotes better outcomes.  Gossop, Stewart, and Marsden (2007)  also found that five years after residential treatment for drug dependence, those who attended NA and AA more frequently had higher abstinence rates from opiates and alcohol than those who attended less often and those who did not attend.  McKellar, Stewart, and Humphreys (2003)  also found that AA participation among more than 2,000alcohol-dependent male military veterans predicted fewer alcohol-related problems that could not be attributed to initial problem severity, motivation, or psychopathology.

Narcotics Anonymous and Other Programs

Narcotics Anonymous (NA) was modeled after AA. Groups began forming in the 1950s often by AA members who were addicted to alcohol and other drugs ( Nurco, Wegner, Stephenson, Makofsky, & Shaffer, 1983 ). NA’s Twelve Steps and Twelve Traditions are almost identical to AA’s, with drug terminology substituted for alcohol terminology. NA emerged separately from AA because some individuals whose sole drug of abuse was alcohol were uncomfortable with individuals addicted to illicit drugs, whom they associated with the criminal element (Nurco et al.). Today, it is common to hear attendees at AA or NA meetings introduce themselves as “alcoholics” and “addicts.”

Cocaine Anonymous, begun in 1982, emerged with the increased use of this drug. The unique aspects of preference for a particular drug may have encouraged the development of this mutual-help group and others, such as Marijuana Anonymous.

There are many other mutual-help groups for people with alcohol and drug problems, some of which are not based on AA principles. Jean Kirkpatrick developed Women for Sobriety (WFS) because she felt AA had a male orientation and that women needed alternatives to help them in their sobriety. WFS is discussed further in  Chapter 15 , along with the more recently developed Men for Sobriety.

James Christopher founded the nonprofit organization Secular Organizations for Sobriety (SOS), also called Save Our Selves. This cognitively-based or rational thought program is an alternative to the spiritually-oriented Twelve-Step programs ( Christopher, 1988 ,  1989 ,  1992 ;  Connors & Dermen, 1996 ). SOS is not critical of other recovery programs. It embraces scientific inquiry about addiction and supports no single theory of addiction. SOS believes it is important for individuals to that they are alcoholics or addicts. It recommends the “Sobriety Priority” (making sobriety one’s primary priority or objective) to break the cycle of addiction, which SOS believes is composed of a chemical or physiological cellular need, a learned habit, and denial. The group’s philosophy is to empower oneself to live a sober life, rather than relying on a higher power or other outside force. Meetings, led by volunteers, are described as “friendly, honest, anonymous, and supportive.” Members are encouraged to utilize the support of other recovering individuals. Family and friends are welcome at meetings.

SMART (Self Management and Recovery Training) Recovery, another organization that seeks to help people recover from alcohol and drug problems, describes itself as having a “scientific foundation, not a spiritual one”. It avoids the labels “alcoholic” and “addict.” It does not utilize the disease concept or the concept of powerlessness, and sponsors are not part of the program. The program is based on Albert Ellis’s rational emotive behavior therapy, which addresses irrational beliefs and using empowerment to abstain. Volunteer coordinators run the meetings and volunteer professional advisors assist the coordinators in their efforts. Members may “graduate” from SMART Recovery, rather than attend meetings indefinitely.

Jack and Lois Trimpey founded Rational Recovery (RR) in 1986. RR is an abstinence-based, self-help approach. RR’s founders believe there is no evidence that addiction is a disease, most people quit on their own, mutual-help recovery groups and professional treatment are harmful, and the only remedy for addiction is voluntary abstinence ( Trimpey, 1996 ;  2003 ). RR describes its trademarked Addictive Voice Recognition Technique (AVRT®) as “education on planned abstinence.” AVRT calls addiction a “beast” or “voice” within a person that needs to be killed. Although RR materials state that “brain chemistry and genetics are irrelevant to recovery,” they also indicate that this beast represents a primitive part of the brain dedicated to survival and pleasure; another part of the brain, the neocortex, allows one to think, solve problems, and recognize and defeat the beast. According to RR, achieving abstinence is an event—a decision to stop using (not a process)—and that it is not nearly as difficult as many people think.

Variations of mutual-help groups, including those for people with co-occurring intellectual disability (mental retardation) and substance use disorders, are generally organized and led by a professional. Groups for those with co-occurring mental illness and substance use disorders may be led by individuals recovering from both illnesses or by a professional with a co-leader who is in recovery from one or both illnesses (see  Chapter 13 ). There are also groups for family and friends of people who have substance use disorders (see  Chapter 10 ). The first to emerge was Al-Anon, founded by the wife of one of AA’s founders. Naranon is for the family and friends of narcotics addicts, and Co-Anon is for the family and friends of cocaine addicts. Alatot and Alateen are for the children of alcoholics

Chapter 7 Preventing Alcohol and Drug Problems

C. Aaron McNeece

Professor and Dean Emeritus, Florida State University

Machelle D. Madsen

Florida State University

Overview of Prevention

The concept of prevention can be defined in a number of different ways. At the national and international levels, the United States and the United Nations advocate one approach to prevention through lowering the available supply of drugs. The U.S. “War on Drugs,” begun in1971, aimed to prevent use by reducing the country’s supply. But, as a zero-tolerance policy, it has been fraught with many problems (see  Chapter 8 ). The power of attitudes has been another major focus of the change. Through the media’s influences, many public and private groups have attempted to prevent substance abuse. For example, The White House Office of National Drug Control Policy (ONDCP) began the National Youth Anti-Drug Media Campaign in 1998 to place advertisements on television, radio, in print, and online. They have also partnered with national organizations such as the American Academy of Pediatrics, corporations such as Procter & Gamble and Television Networks, providing subsidies for anti-drug content ( ONDCP, 2009 ;  Forbes, 2000 ).

At the grass-roots level, there has been increasing involvement of volunteers in organizations and local action-oriented groups, such as Mothers Against Drunk Driving (MADD), Students Against Destructive Decisions (SADD), Partnership for a Drug Free America, and hundreds of parent and community-based antidrug organizations. These groups have succeeded in developing specific constituencies for prevention programs—something that was lacking in earlier efforts, which focused primarily on schoolchildren. It is difficult to disagree with their specific objectives, such as protecting the public from drunk drivers, and collaborating with communications professionals, researchers, and parents to promote drug-free lifestyles. These groups are also free of the disciplinary and procedural constraints that have handicapped many of the chemical dependency professionals working in prevention programs. For instance, MADD and SADD have taken their concerns directly to the legislative arena and the media to get their point of view across. Neighborhood groups have organized public demonstrations outside the homes of suspected drug dealers. Groups such as Neighborhood Watch have mobilized as neighborhood patrols and have notified authorities when drug transactions and impaired drivers are seen. Recognizing the capabilities of these groups, major organizations such as the National Highway Traffic Safety Administration ( NHTSA, 2001 ) and the International Association of Chiefs of Police (IASCP, 2006) recommend to law enforcement officials that they build partnerships in the community with these types of organizations. The Community Anti-Drug Coalitions of America (CADCA) is a unifying agency for such action-oriented groups. It was created at the advice of the President’s Drug Advisory Council in 1992 to respond to the growing number of substance abuse–related coalitions to help them become more effective agents of change ( CADCA, 2009 ).

Community groups have advocated for broad changes in policies and practices at all levels, from the grass roots to Washington, and many have developed a national leadership to advocate for reform. There is evidence of the impact of this movement in such issues as Proposition 99 in California. Despite a $20 million campaign by the tobacco industry to defeat it, voters passed an initiative raising taxes on tobacco products by 25 cents and designated the money for youth-oriented preventive education, research, and health care for people with tobacco-related medical problems ( Wallack & Corbett, 1990 ). The tobacco industry has continued to lobby against restrictions on smoking in public places ( Barnoya & Glantz, 2006 ), despite evidence that bans on smoking in both restaurants and bars have had no detrimental impact on their revenues ( Martin, 1999 ;  Neergaard, 1997 ;  Ponkshe & Wilson, 1999 ). The multistate settlement against the tobacco industry will amount to $195.9 billion in payments by the year 2025 ( Wilson, 1999 ). Coupled with other lawsuits and issues extensively considered by Congress, a more radical approach is emerging in both preventing tobacco addiction and dealing with the adverse health consequences of smoking.

The new approach is more consistent with a harm-reduction model of prevention, rather than the zero-tolerance philosophy that is still favored by federal law enforcement agencies( Office of the National Drug Control Policy, 2001  also see  Chapter 8 ). The objectives of a harm-reduction approach are to reduce the mortality and morbidity associated with alcohol and drug-related problems as well as to reduce the rates of abuse for alcohol and drugs. The more comprehensive view includes social, cultural, and legislative aspects of prevention, rather than simply emphasizing individual responsibility ( Wallack & Corbett, 1990 ).

Environmentally and culturally targeted approaches focus on the social and economic aspects of substance availability and stress objectives designed to reduce the severity of substance-related injuries ( Moskowitz, 1989 ). Some environmentally oriented programs have specifically targeted young people. A good example of the approach was the change in minimum age of consumption laws during the early 1980s ( Wagenaar, 1986 ). The social aspects are stressed in the ad campaigns that tell us “Friends don’t let friends drive drunk.” Another example of the cultural aspects of prevention can be seen in tobacco advertising and responses by various cultural groups to that advertising. According to the  Tobacco Control Research Digest (1999) , tobacco advertising represents 60 percent of the advertising space for most African American newspapers, compared to 12 percent in mainstream advertising. However, a “swift and powerful backlash” by African American community groups was able to force two minority-targeted brands of cigarettes, Uptown and X, to be pulled from the market. Culturally, the use of tobacco in classrooms, boardrooms, and the workplace has become more of an exception than a tradition.

Harm reduction is a utilitarian approach, one that argues for the greatest good for the greatest number of people and one that recognizes that the indirect consequences of abuse and dependency may be far more serious and widespread than is generally believed ( Blane, 1986 ). Perhaps the best example is the high fatality rate associated with alcohol-related automobile accidents. Another is the high rate of infection (hepatitis, AIDS, etc.) associated with sharing needles among intravenous drug users. Still another is the high crime rate associated with using certain illicit drugs, such as methamphetamines. Advocates of harm-reduction approaches assume that certain drugs will always be abused. By recognizing that many college students abuse alcohol, for example, efforts might be turned toward preventing the students from driving while intoxicated by providing free transportation. A more realistic approach to intravenous drug use might be able to halt the spread of certain diseases by providing clean needles and syringes to people addicted to heroin.

Research emerging from this broader perspective is showing that an ecological approach ( Brofenbrenner, 1979 ) to substance abuse prevention is more effective in preventing substance abuse. For example, a joint four-year project of the United Nations Office on Drugs and Crime and the World Health Organization in eight rapidly changing countries found that substance abuse prevention is most effective when it includes schools, families, youth groups, law enforcement, and health service workers. Programs need to include a range of risk and protective factors across a wide intervention perspective—from reducing individual demand to reducing the availability of substances ( WHO, 2007 ). Because of this shift, the United Nations Office on Drugs and Crime now focuses drug prevention work in three core areas rather than just youth: families, schools, and the workplace (2010).

Using a traditional public health model, prevention efforts may be classified as primary, secondary, and tertiary. Preventing new cases from occurring, such as convincing elementary school students not to smoke, is primaryprevention. Reducing the number of existing cases, generally by identifying and treating those who have a drug or alcohol problem, is secondary prevention. The effort to avoid relapse and maintain the health of those who have been treated is tertiary prevention ( Kinney & Leaton, 1987 ).

The Institute of Medicine has utilized a prevention paradigm consisting of three completely different categories or levels: universal for the general population, selective for particularly defined populations at highest risk, and indicated for persons already showing problems and requiring intervention to halt progression to more serious problems. This framework may add a more proactive dimension to community-based and individually focused prevention efforts because of its targeting preventive efforts along an operationally applied continuum ( Mrazek & Haggerty, 1994 ). In 1998, researchers at the National Institutes of Mental Health (NIMH) revisited these categories, looking at issues such as pre-interventive research. Zerhouni uses the “four Ps” to describe preventative medicine: predictive, personalized, preemptive, and participatory to engage individuals with facts and services long before problems occur (2006, p. 3). Although the categories have not changed in places like the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry of Evidence-based Programs and Practices ( NREPP, 2010 ), protective factors in a person’s life that work to prevent drug use before an intervention takes place and ameliorate severity and relapse after a problem occurs are now being emphasized across many different prevention strategies and ecological contexts ( National Research Council & Institute of Medicine, 2009 ;  Weisz, et al., 2005 ).

Preventive strategies may be grouped into five major categories including: public information and education; service measures; technologic measures; regulatory, legislative, and economic measures; and family and community approaches. Some of these strategies may be directed at preventing or decreasing the use or abuse of alcohol or drugs; others focus on reducing or eliminating the harmful consequences of alcohol and drug use, both to the user and the larger society. All of these, including those that emphasize spirituality and cultural factors, will be discussed in the following pages, but first we will present a brief overview of prevention efforts.

Drug problems among U.S. youth became a public concern in the middle to late 1960s. Obviously, young people had been abusing alcohol before this time, but prevention efforts were relatively insignificant until large numbers of children began experimenting with illicit drugs. The early prevention efforts were based on the information deficitapproach—that children lacked adequate education about the dangers of substances ( Belcher & Shinitzky, 1998 ). During the early 1970s, the belief prevailed that arousing fear would stop substance abusers. Little evidence, however, supported this position, even in cases of life-endangering situations. For example, even after a heart attack, many victims soon return to previous unhealthy behaviors, including smoking ( Evans, 1998 ). In the late 1970s through the early 1990s, the majority of prevention programs focused on ways to reduce the demand for drugs and alcohol, most often by trying to change individual behavior within the venue of social and interpersonal influence. The prevailing attitude was that youth experimented with drugs because their internal value system had not sufficiently developed to resist external pressures ( Belcher & Shinitzky, 1998 ;  Evans, 1998 ). Few of these programs had successful results beyond superficial and transient changes in knowledge and attitudes (Klintzner, 1988;  Tobler, 1997 ). One can change both knowledge and attitudes concerning drugs only to discover through rigorous research that it has little effect on behavior ( Kinney & Leaton, 1987 ). In the 1990s, more comprehensive, research-based, culturally relevant, age-appropriate, interactive, and family-based programs appeared. These types of programs demonstrated more success in the prevention of substance abuse ( Belcher & Shinitzky, 1998 ;  Kumpfer, 1998a ;  Tobler, 1997 ). Even though professional writings encouraged utilizing these newer approaches, the more traditional educational, non-interactive methods continued to be employed throughout school systems, despite lack of evidence of their effectiveness ( Sager, 2000 ;  Tobler, 1997 ). Some of these more traditional programs, still in use today, refer to research evidence supporting their existence; however, the research methods they utilize tend to be quite weak. A major change in the 1990s was that prevention developers and researchers began to address theoretical issues that cut across common areas of concern regarding alcohol, tobacco, and illicit drugs. They began looking at risk and protective factors as they affect high-risk behaviors, including substance abuse ( Catalano et al., 1998a ;  Evans, 1998 ;  Pandina, 1996 ).

In the 2000s, researchers have begun looking more closely at these risk and protective factors regarding substance abuse across areas of race/ethnicity, gender, social context, spirituality, family dynamics, and education ( Delva, Mathiesen, & Kamata, 2001 ;  James, Kim, & Armijo, 2000 ;  National Center on Addiction and Substance Abuse and Columbia University [CASA], 2001a ;  Paschall, Flewelling, & Faulkner, 2000 ;  Vakalahi, 2001 ). This information is now being consolidated to incorporate multidimensional approaches to programs. Research has indicated that these more comprehensive programs are more effective in influencing drug use behavior ( Streke, 2004 ).

Evidence-based programs can now be submitted to a review process by SAMHSA’s National Registry of Evidence-based Programs and Practices ( NREPP, 2010 ). This registry looks at the quality of the research supporting each intervention and the readiness for dissemination to the public. These aspects are rated independently. If approved, they are considered model programs and posted on their website with relevant information about the intervention, including costs, populations served, outcomes, and so forth. In relation to populations served, the large majority of the 58 interventions listed (84 percent) targeted children and adolescents; 38 percent of the interventions focused on young adults, 31 percent covered26–55 year old adults, most of which were incorporated as families supporting their children’s involvement in a program. Only six programs included older adults. Four of these were workplace interventions, and the other two were community level interventions. None focused on the specific needs of retired older adults. The greatest number of programs (50) focused on alcohol, tobacco, and marijuana. Thirty-two programs included other drugs. According to the Monitoring the Future Survey of substance use in teens, non-medical use of prescription drugs continues to be a widespread problem. Seven of the top 10 drugs most likely to be misused by 12th graders were either prescription or over-the-counter medications ( National Institute on Drug Abuse, 2009 ).

However, only four of the NREPP-listed programs specifically addressed the misuse of prescription drugs. Two of the four were programs for athletes focusing primarily on steroid misuse. The costs of these programs varied widely, from a free tobacco prevention program to an intervention that costs well over $35,000 a year. The mean rating of the quality of research supporting the programs (on a scale of 0.0–4.0) varied from .95 for Keeping a Clear mind (which also had a low readiness for dissemination score of 1.8) to 4.0 for Project Alert (with a readiness for dissemination score of 3.8). Another very high performing program was Life Skills Training, with an experimental research mean score of 3.93 and a readiness for dissemination score of 4.0.

Some researchers question the usefulness of the evidence-based label for these programs due to data analysis procedures that capitalize on the chance of obtaining statistically significant results ( Gorman & Huber, 2009 ). We must also consider that programs may sometimes have detrimental effects. We usually think of prevention programs as being benign, but in a review of the substance prevention literature,  Werch & Owen (2002)  found 17 programs that increased substance abuse among children, adolescents, and young adults. Some had statistically significant negative outcomes on increased experimentation and abuse over time. Carefully reviewing outcomes of the various prevention programs and then acting on that information is a vital process in choosing an appropriate prevention method for a specific population.

Even in light of the new evidence-based programs, several questions need attention. With the overwhelming focus on alcohol and tobacco, do the ecological influences operate in the same manner regarding the different types of substances? If a prevention program is assessed a failure, do we know why it failed? How are the individual protective factors which decrease the probability of substance problems interrelated? Despite the seriousness of polydrug use, programs focusing on alcohol, tobacco, and other drugs have maintained their conceptual distinctness in practice. Until recently, professionals have tended to focus on differences in their areas of specialization, rather than seek common ground ( Wallack & Corbett, 1990 ). On a broad scale, prevention program practice is just now beginning to catch up with new trends in the research literature. However, many outmoded, ineffective practices remain in use.

Public Information and Education

Information and education are explicit elements in most drug and alcohol prevention programs. Tremendous emphasis has been placed on public information and school-based education as a primary means of prevention throughout the United States. However, these approaches to changing behaviors rooted in deeply held social values have been marginally effective, at best ( Blane, 1986 ;  Evans, 1998 ;  Hopkins et al., 2001 ). Nevertheless, it is still widely accepted that informational approaches should be included in programs designed to prevent drug use ( Wallack & Corbett, 1990 ). Universal prevention programs aimed at education for all students in school are generally shorter and less costly. However, they are frequently not able to adequately reach racial/ethnic groups and high-risk youth and families.

While we would all like to believe that drug education will deter young people from using drugs, evaluations of most types of drug education programs from all over the developed world have shown that this is not the case. Perhaps one of the reasons for this failure is that drug education is often based not on sound educational principles but on a narrow view that skews and censors information. This is not education but propaganda. Young people respond to this by saying what they think parents, teachers, and politicians want to hear, rather than what they really believe ( Cohen, 1996 ). This can lead to adults’ drawing inaccurate conclusions about the effectiveness of these programs. Prevention programs and models have become somewhat of an ideology to those who steadfastly support them, and ideologies are very resistant to data.

Under highly specific conditions, public information campaigns can sometimes achieve certain limited goals. There is evidence that programs directed at increasing the number of people inoculated for infectious diseases, increasing the response rates for census reports, and getting taxpayers to file by the deadline all have met with a measure of success ( Blane, 1986 ). Health education in the public schools is another matter, however (Blane, 1977; Kumpfer, 1998a). This should come as no surprise, since health education has traditionally not been accorded a high priority in the public schools. Teachers often view it as an intrusion and a drain on the so-called legitimate goals of the educational process. Programs are ill conceived, lack clear-cut objectives, and are not designed to engage student interest and involvement. Teachers generally receive little training in how to present the material. Students, perhaps reflecting school and teacher attitudes, typically regard health education as a required bore. It is no wonder that purely educational programs are, at best, marginally effective ( Blane, 1986 ;  Kumpfer, 1998a ;  Hopkins et al., 2001 ).

Public information and education efforts directed at adults have been much more limited. The primary adult educational programs are “DUI schools.” These are designed for persons who generally have long histories of driving under the influence violations and even longer histories of alcohol abuse, but many of their clients are probably not alcoholics. With such a varied group of clients, it is not surprising that their effectiveness is also marginal. Paradoxically, they are probably more successful with the substantial number of students who are not really alcoholic or drug dependent.

There has been a dramatic increase in mass media campaigns dealing with alcohol, drugs, and smoking in recent years. Strategies are aimed at getting children to “just say no” to drugs, at convincing adults to drink in moderation, at convincing drivers not to get behind the wheel after drinking, and at convincing everyone to quit smoking by understanding the truth about tobacco use.

However, advertising promoting these tobacco and alcohol products has resulted in a stronger identification with them (such as Camel No.9). Identification is also associated with higher levels of use in children and adults (Pierce, Gilpin, & Choi, 1999; Villani, 2001; Wyllie, Zhang, & Casswell, 1998). These strategies can, however, be offset in adolescents by parental reinforcement and counter-reinforcement of messages (Austin, Pinkleton, & Fujioka, 2000). As a prevention tool, media campaigns appear to have had limited success in reducing the use of tobacco, alcohol, and marijuana (McCaffrey, 1999). In a meta-analysis of health-related media campaign studies only a small effect size was noted for changes in behavior relating to smoking. Approximately 2 percent of effect related to the targeted audience was thought to be due to the campaigns. However, even a small change in a large number of people can save lives. The authors suggest that the small effect may be impacted by the fact that addictive behaviors are more dependent on environmental factors than a simple media campaign can overcome(Snyder et al., 2004). For example, the authors compared their media results with a phone counseling meta-analysis which yielded a 6 percent change in smoking behavior (Lichtenstein, Glasgow, Lando, Ossip-Klein, & Boles, 1996 as quoted by Snyder et al., 2004).

But even these modest declines in consumption are difficult to tie directly to media prevention efforts alone. A meta-analysis of interventions to increase tobacco cessation demonstrated the effectiveness of media campaigns when they were implemented with other interventions of support (Hopkins et al., 2001). The campaigns have also been effective in reducing children’s exposure to environmental tobacco smoke. With a few exceptions, such as the Florida “truth” campaign (Sly, Heald, & Ray, 2001; Sly, Hopkins, Trapido, & Ray, 2001), the evidence does not prompt excessive optimism (Hopkins et al., 2001; Olson & Gerstein, 1985). As discussed later, one study by Siegel (2002) found that the success of anti-tobacco advertising is threatened by the political power of the tobacco lobby.

Programs Directed at Children and Adolescents

Throughout the 1970s, most drug abuse prevention programs were educational in nature, directed at adolescents, and implemented through the schools. Early programs relied on providing information and using so-called scare tactics. These programs were generally so ineffective that they were denounced by the federal government’s Special Office for Drug Abuse Prevention (SODAP). In fact, SODAP was so disillusioned that it imposed a temporary ban on the funding of drug information programs (Wallack & Corbett, 1990).

Growing evidence of the ineffectiveness of these strategies led to a trend toward use of affective education and other alternative approaches (Wallack & Corbett, 1990). Affective programs assumed that adolescents would be deterred from using drugs if their self-esteem, interpersonal skills, and techniques for decision making and problem solving could be improved. Recreational activities, community service projects, and involvement in the arts were stressed as a way of providing meaningful, fulfilling experiences that would counteract the attractions of drugs. The affective model was developed as a result of research on the correlates of drug-using behavior, primarily among delinquents and addicts (Dembo, 1986). These studies identified drug-abusing youths as less likely to participate in clubs, youth organizations, and religious activities. Generalizing from that population to so-called normal adolescents may have led to a faulty model for prevention efforts. However, the community involvement aspects were a step in the right direction because less comprehensive approaches, such as those that target self-esteem alone, are no more effective than education alone in reducing drug use (Braucht & Braucht, 1984; Kumpfer, 1998a). To be effective, programs must be interactive and based in a broad framework like the Life Skills Training programs which have shown effective results in reducing alcohol, tobacco, and marijuana use (Botvin et al., 2000).

Early smoking prevention programs were also information oriented and frequently resorted to scare tactics, such as showing students photographs of cancerous and healthy lungs. Like the early alcohol and drug prevention programs, they had little impact on long-term behavior. Confronted with this lack of success, some researchers began to consider ways of addressing the social milieu in which young people begin smoking. This eventually resulted in a new generation of smoking programs that have been somewhat more successful (Hopkins et al., 2001).

Drawing on Evans et al.’s (1978) social inoculation theory (1978) and McGuire’s (1969) concept of cognitive inoculation, this approach argues that if adolescents are provided with counterarguments and techniques with which to resist peer pressures to smoke, as well as factual information about smoking, they are more likely to abstain. Based on this approach, many smoking prevention programs focused on the short-term effects of smoking, rather than long-term health consequences with slogans like, “When he kisses you, do you really want your breath to smell like an ashtray?” The impact of this approach is well documented in delaying young people’s use of tobacco for up to two years (McCarthy, 1985). However, long-term effects were not demonstrated, and even the short-term effects appeared to decay with time (Wallack & Corbett, 1990).

Many elements from the social inoculation and affective education models were used in developing Project D.A.R.E. (Drug Abuse Resistance Education). This program was originally developed as a joint project of the Los Angeles Police Department and the Los Angeles Unified School District in 1983. Now, millions of children in communities across the world participate (D.A.R.E., 2009). Project D.A.R.E. was originally designed to help fifth- and sixth-grade students recognize and resist the peer pressure that frequently leads to experimentation with alcohol and drugs. Some lessons focused on building self-esteem, whereas others emphasized the consequences of using alcohol or drugs and identified alternative ways of coping with stress, gaining peer acceptance, or having fun. Most importantly, students learned and practiced specific strategies for responding to peers who offer them drugs. Ways to say “no” include changing the subject, walking away or ignoring the person, and simply saying no and repeating it as often as necessary. The original curriculum was organized into 17 classroom sessions conducted by a police officer, coupled with other activities to be taught by the regular classroom teacher (DeJong, 1987; Los Angeles Unified School District, 1996). The D.A.R.E. program happened at just the right time. With the enthusiasm for drug-free schools and the funding for prevention efforts that proved politically popular in the 1980s, the D.A.R.E. program grew exponentially. By 1991, D.A.R.E. programs were found in every state, and the Drug-Free Schools and Communities reauthorization bill of 1991 required that each state use at least 10 percent of its share of the funds to support D.A.R.E. (Ray & Ksir, 1999).

One of the earliest evaluations of the D.A.R.E. program found that students who received the full-semester D.A.R.E. curriculum during the sixth grade had significantly lower use of alcohol, cigarettes, and other drugs. The impact was much greater for boys (who used more drugs to begin with) than for girls (DeJong, 1987). A later longitudinal (three-year) study found significantly lower use rates by D.A.R.E. graduates for all drugs except tobacco (Evaluation and Training Institute, 1988). However, the most comprehensive evaluation of D.A.R.E. by the Research Triangle Institute found the program to be ineffective in preventing or reducing drug use (Ringwalt et al., 1994). D.A.R.E. officials and the U.S. Department of Justice both disavowed the report, and D.A.R.E. tried to prevent others from publishing similar criticisms (Glass, 1997). Then, a follow-up of over 1,000 individuals 10 years after graduation from D.A.R.E. found few differences between D.A.R.E. and non-D.A.R.E. participants, and in no case did the D.A.R.E. group have a more successful outcome than the comparison group (Lyman et al., 1999). The program still shows little evidence of long-term effects on drug use (Pan & Bai, 2009).

Even in light of the more recent and comprehensive research, anecdotal evidence and lack of dissemination of research findings have kept this ineffective program alive. For example, U.S. Senator Bob Coffin of the Senate Committee on Finance for the state of Nevada supported D.A.R.E. because his son had recently finished the program, “and it seemed to work very well for him and all of his classmates” (Minutes of the Senate Committee, 1999, p. 12). Despite the absence of solid evidence, he urged continued support for D.A.R.E.

The repeated failure of D.A.R.E. to demonstrate long-term effectiveness has not resulted in its abandonment, even though costs as of 2000 were thought to be $220 million per year(Sager, 2000) and have been estimated as high as $1–$1.3 billion per year (Shepard, 2001). A number of states, however, are searching for other alternatives. D.A.R.E. America is countering with the argument that one semester of fifth- or sixth-grade prevention programming is simply not enough. It is encouraging the adoption of booster programs in junior high and high school, as well as the introduction of D.A.R.E. in earlier grades (Ray & Ksir, 1999). One such add-on program, now partnering with D.A.R.E., Keepin’ it Real, has demonstrated significant results in reduced alcohol use (Kulis et al., 2007).

A number of schools have turned to alternative models of school-based prevention programs altogether. Although these programs are still education-based, they also incorporate more aspects of a child’s environment. For example, the schools in Hillsborough County (Tampa), Florida, have never had the D.A.R.E. program. For about 20 years, they have used the “Too Good for Drugs” program, created by the Mendez Foundation. It is a school-based program that utilizes the latest research about resiliency, risk, protective factors, and developmental assets factors—all of which have been identified as crucial for young persons’ successful growth and development (Benard, 1993; Hall & Ziglar, 1997; Hanson, 1992).

Project ALERT is a program that began in California and Oregon high schools and targets tobacco, alcohol, and marijuana use. Unlike D.A.R.E., ALERT uses trained educators with the assistance of teen leaders. The program is delivered to seventh-grade students, and three booster lessons are provided in the eighth grade. Compared to a control group, the experimental group drank less alcohol and smoked less tobacco and marijuana at the end of the program. The reduction in alcohol use diminished over a 15-month follow-up, but the decrease in tobacco and marijuana use was still significant (Ray & Ksir, 1999; Ellickson et. al, 2003). Project STAR is another program aimed at junior high students that (like both D.A.R.E. and ALERT) is based on a social influence model. STAR is delivered over a two-year period, and it includes parents in homework assignments and communication training. Seniors who had completed the program in junior high were much less likely to use alcohol, tobacco, and marijuana (Johnson, MacKinnon, & Pentz, 1996). Another successful example is the Life Skills Training Program. It is a three-year program based on the social influence model and covers resistance skills, normative education, media influences, self-management skills, and general social skills. The program’s effectiveness has been demonstrated in both two-year and six-year follow-ups (Botvin, Schinke, Epstein, Diaz, & Botvin, 1995; Botvin et al., 2000).

According to Dusenbury and Falco (1995), experts believe that effective school-based drug abuse prevention programs must have these components:

1. They are research based and theory driven.

2. They provide developmentally appropriate information about drugs.

3. They utilize social resistance skills training.

4. They include normative education.

5. They are presented within a broader context of skills training and comprehensive health education.

6. They use interactive teaching techniques.

7. They provide teacher training and support.

8. They cover prevention issues adequately and provide sufficient follow-up.

9. They are culturally sensitive.

10. They include other components (family, community, media, special populations, etc.) that enhance the program’s effectiveness.

11. They contain an evaluation method.

Prevention efforts are now beginning to focus on the interplay of risk factors, protective factors, and resilience. Risk factors are those aspects across ecological systems that increase the chance that a person will have problems with substances. They include individual issues such as mental illness and genetic tendencies towards addictions; family, school, and social issues such as a history of physical or sexual abuse and affiliations with those who use drugs; community issues such as poverty and accessibility of substances; and cultural issues, including cultural acceptance and media images of substance use (Ammerman, Ott, & Blackson, 1999). Protective factors are those aspects across ecological systems that increase the chance that a person will avoid problems with substances. They include individual issues such as creative problem solving and self-value; social issues such as family, school, positive adult role models, and supportive relationships; and community issues such as a safe neighborhood environment and availability of wholesome activities.

Beginning with the work of Garmezy (Garmezy, 1981; Garmezy & Newuchtrelein, 1972) and Werner and Smith (1982, 2001), models of prevention and coping with difficulties have shifted from a deficit model to a resilience model. These and other authors followed young children through adulthood, identifying risk and protective factors that lead to resilience. Resilience focuses on protective factors found in youth from high-risk situations. It is a phenomenon which empowers a person to return to functional status despite high-risk events. It is observed through adaptive functioning and enabled by protective factors which act to offset negative influences. It is most clearly demonstrated when the individual, community, and family are all working together to facilitate progress toward positive life functioning. Theoretical frameworks applying resilience specifically to substance abuse have been explored(Berlin & Davis, 1989; Brown, 2001), and programs that focus on developing these factors in youth are being encouraged to decrease drug abuse (Glantz, 1995; Hanson, 2001). Some researchers have found effective results in developing these skills (Cesarone, 1999; Kumpfer, 1999). However, more research is needed to determine if resilience related skills, when taught to youth, are effective in curbing drug use.

Programs Directed at College and University Students

In keeping with the newer ecological focus on attitudes and relationships, evidence-based programs are emerging specifically for college campuses. For example, Challenging College Alcohol Abuse is a program that began at the University of Arizona and uses social norms and environmental management through venues such as media campaigns to address misperceptions about drinking. This approach is based on evidence that college students tend to think that the drinking behavior of other students is higher than it actually is. The program provides small grants to fund alcohol free social events. They also encourage increased monitoring of student alcohol use. Students impacted by this program demonstrated significant decreases in heavy drinking, frequent drinking, and negative consequences of alcohol use (Glider et al., 2001).

A similar project is being conducted at Florida State University called the Real Project. It collects data from students at the university about actual drinking habits and publishes those around campus. The surveys show that the students’ perceptions of drinking were much higher than actual drinking. The project advertises dry events and is present on social networking sites. As a result, from 2002 to 2009, a 20.9 percent reduction was found in high-risk drinking behaviors, and there was a 24.8 percent increase in students who report drinking moderately and a 17.3 percent increase in those who abstain from drinking altogether (The Real Project, 2008). Additionally, the university provides a clear substance policy and readily available services for students with substance use problems. It appears that clear policies coupled with multi-faceted approaches including social norms can be a helpful prevention strategy in the college and university setting.

The most important conclusion to be reached after 30 years of organized prevention programming is that no single strategy has consistently demonstrated a long-term impact, and many experts believe that it may be a mistake to think in terms of a single-strategy solution (Belcher & Shinitzky, 1998). In many respects, life has become more complicated for the current generation. Experimentation may be seen as a normal rite of passage for many youth—a phase that most will outgrow. The problem is that many young people find themselves in very difficult situations physically and emotionally when these experimentations go awry. Previous generations of youth experimented mostly with alcohol. The greater availability of illicit drugs provides today’s youth with a greater variety of choices. Education alone does not demonstrate overwhelmingly positive results. Prevention efforts, therefore, must become more comprehensive. A mixture of community, education, family, and skills training with the other measures described shortly may result in a much more effective approach to prevention.

Service Measures

Service measures (detoxification, therapeutic communities, 28-day treatment programs, Alcoholics Anonymous, etc.) are aimed at ameliorating or reversing a condition resulting from alcohol or drug use or reducing the chances of its onset among members of a high-risk population. In traditional community health terms, such measures usually fall into the secondary or tertiary prevention category. Service measures are not generally emphasized in prevention because of their ameliorative or restorative nature. Their lack of popularity among prevention experts is due to the fact that, by definition, they are directed toward remediating an existing problem, rather than preventing new cases from occurring.

Service measures are also labor intensive and therefore comparatively expensive. They may often require large capital outlays for facilities and personnel, making them not particularly cost effective. Service measures also are usually focused on the individual, whereas prevention specialists are more comfortable with strategies that apply to large populations. Additionally, when mandated to “do prevention,” providers are inclined to allocate resources to specific types of services while neglecting other types of preventive measures (Kumpfer & Kaftarian, 2000). When dealing with the serious nature of a client’s alcohol or drug problem, most counselors or therapists find little time for prevention work.

Early intervention services—such as those provided in occupational alcoholism programs, “troubled worker” programs, and employee assistance programs—are a common type of secondary prevention. These programs are oriented toward employees whose work performance is impaired by the use of drugs or alcohol. Most referred employees are people addicted to alcohol or drugs with long-standing problems, rather than individuals who are at risk for first time chemical dependency (see Gould & Smith, 1988).

According to a study by Roman and Blum (1990), only about 4 percent of the employees in a firm with an employee assistance program (EAP) utilize the services in a given year, and only 1.5 percent specifically present a substance abuse problem. Harrison and Hoffman (1988) found that the employer was mentioned as a primary motivator for treatment admission by only one-sixteenth of inpatients and one-tenth of outpatients. However, Lawenthal et al. (1996) reported that levels of improvement were similar between employees who were coerced into treatment based on urine screens and those who were self-referred Awareness of the EAP services, support for the company policies, and intolerance of coworker substance abuse may increase the utilization of EAP services(Reynolds & Lehman, 2003).

Chemical dependency manifests itself in the workplace in four ways. First, an employee may be chemically dependent. Second, an employee may be affected by a spouse, child, or other loved one who is chemically dependent. Third, an employee may be an adult child of a chemically dependent parent. Finally, an employee may be selling or using drugs in the workplace (DiNitto, 1988). To intervene at the earliest possible stage of dependency, supervisors are taught to be alert for the following common symptoms of alcohol or drug abuse:

· Chronic absenteeism

· Change in behavior

· Physical signs

· Spasmodic work pace

· Lower quantity and quality of work

· Partial absences

· Lying

· Avoiding supervisors and co-workers

· On-the-job drinking or drug use

· On-the-job accidents and lost time from off-the-job accident. (Kinney & Leaton, 1987)

Assuming that early identification and treatment are achieved in a workplace program, the chances of recovery should be increased for these reasons:

1. The threat of job loss is a significant motivator.

2. The family may still be present to provide emotional support.

3. Physical health has not deteriorated seriously.

4. The client’s financial resources are not depleted.

Although studies have reported that chronic drug use negatively impacts employment status, casual drug use does not (French, Roebuck, & Alexandre, 2001). As many as 70 percent of those who admit to using illicit drugs, work regularly (Marwick, 1999). It would seem that work can therefore be utilized as a positive tool in aiding workers to seek treatment. However, ethical company policies, current research, and state and federal laws should guide employers in developing interventions that do not infringe on the rights of employees.

Workplace programs use early intervention (service) measures as one component of more comprehensive prevention efforts. Other components include information sessions, substance abuse issue discussions, posters and pamphlets, use of peer pressure, and financial incentives. Such incentives may take the form of cash benefits to employees who quit smoking or reduced insurance rates for healthy lifestyles. Employers are convinced that a healthier work force results in greater organizational efficiency and higher profits.

Although Driving Under the Influence (DUI) programs were considered earlier as educational prevention, they also could be considered as early intervention. In addition to the educational component, offenders are offered treatment and probation instead of fines, jail, and other punishment. The effectiveness of treatment offered under such compulsion is questionable, however (Homel, 1988), just as in workplace programs, the clients are also likely to be those with long-standing problems of chemical dependency, so the appropriateness of the “early intervention” label is equally questionable.

A number of pilot early detection, screening, and treatment programs have been funded by the U.S. Department of Justice. For example, in Miami, where the first Juvenile Drug Court was founded in 1989, juvenile offenders are routinely screened at detention through urine analysis. As of the early 1990s, those who tested positive for any of five major drugs (about 85 percent) were referred for treatment by local agencies. Because of a lack of follow-up, however, fewer than half the youth referred actually went to treatment, and only about one-third of them completed a treatment program. (Miami/Dade County Juvenile Screening, 1991). Today, Miami/Dade is at the forefront again, this time with more impressive results. First, the Florida Legislature established Juvenile Assessment Centers which coordinate the agencies that work with youth who have been arrested. Partnering with researchers under federal grants, the groups determined to implement evidence-based best practices including focused service measures for differing offenders. In April 2007, the Civil Citation Program was created which allowed police officers to refer a child for services after a minor offense without making an arrest. The program became a true systemic prevention model, enlisting all 37 local arresting agencies and working in cooperation with the public schools and local treatment facilities. Between 1998 and 2008 total arrests were down by 46 percent and, of the 4,700 youths referred, 81 percent successfully completed the evidence-based interventions. Re-offenses were reduced by 80 percent (Miami-Dade County Juvenile Services Department [JSD], 2009a).Furthermore, in 2008, an economic study concluded that this reformed juvenile justice system saves the Miami community over $33 million a year. According to JSD (2009b), approximately three quarters of the clients were drug offenders. It has been hailed as an exemplary model by several U.S. and international agencies (Walters, 2009). Service measures can be very effective in preventing substance abuse when implemented in a comprehensive and creative manner with research informing the intervention.

Technologic Measures

In the traditional public health prevention model, technologic measures refer to “modifications in the noxious agent or the environment in which it operates that will affect the relationships among the agent, the environment, and members of a population to reduce the rate of occurrence of a disorder” ( Blane, 1986 ). Although relatively new in chemical dependency, technologic measures are commonplace in occupational health and safety, transportation, and water sanitation.

Efforts to alter the noxious agent itself generally have been limited to modifications of alcohol and tobacco products. Cigarette makers produce a variety of so-called light brands that are lower in nicotine. Manufacturers of distilled spirits have actually decreased the average amount of absolute alcohol in their products over the past several years, and more brands of low-alcohol beer become available each year. At first, these low-alcohol brands seemed to be socially acceptable only in Europe, but they have now become quite popular in the United States. Biomedical researchers are still searching for a breakthrough that will eliminate the negative physiologic and psychological effects of alcohol. Some even have hope of developing a practical “sobering-up” pill. On the medical front, nicotine vaccines are being developed that interact with the nicotine to prevent the reward mechanism. With the NicQbvaccine, it was found that patients who were able to create antibodies to the nicotine had significantly greater abstinence from tobacco, compared to those given a placebo. As of 2010, however, nicotine vaccines were still in pre-clinical developmental trials ( Jupp & Lawrence, 2010 ).

As mentioned in  Chapter 6 , antagonist therapies have been developed for drugs such as heroin addiction. Drugs such as naloxone, naltrexone, and cyclazocine block the action of the opiate drugs. A newer drug, Suboxone, is a partial receptor agonist, a drug which actively binds to a receptor cell, and part receptor antagonist. But these drugs do not prevent withdrawal symptoms. Patients are withdrawn from heroin before being given these drugs. The prior user who returns to using heroin while taking a narcotic antagonist will find it impossible to get high ( Blane, 1986 ). An agonist, such as methadone, is a drug used to prevent symptoms of heroin withdrawal, and it also diminishes the effects of heroin. The heroin addict who is taking methadone will not be able to get the same high from using heroin.

The manufacturer of OxyContin, Purdue Pharma, released a ten-point plan to make this drug less susceptible to abuse. The plan included such measures as tamper-resistant prescription pads, which include six security devices that make them almost impossible to copy (“Drug maker to help curb painkiller abuse,” 2001), and the possibility of adding naloxone to the primary ingredient oxycodone to prevent abusers of that drug from getting any euphoric effect. As of early 2010, OxyContin did not contain naloxone due to variability in absorption. But, with support from the FDA, Purdue continues the study of interventions to reduce abuse, such as a plastic coating on the pill ( Perrone, 2009 ). The naloxone/oxycodone combination is available as the drug Targinact in the United Kingdom to reduce gastric side effects ( Napp Pharmaceuticals, 2009 ). The Food and Drug Administration (FDA) has recently moved to work towards technologic and other risk-management measures with all major pharmaceutical companies that produce opioid drugs. Antabuse (disulfiram) is a drug that prevents the normal metabolization of alcohol. A person who ingests alcohol while taking Antabuse will experience an accumulation of acetaldehyde, resulting in severe physical consequences such as difficulty in breathing, nausea, dizziness, vomiting, and blurred vision. In some cases, people are able to continue drinking despite the symptoms, however ( White, 1991 ). A newer drug, Acamprosate, works with the GABA neurotransmitter systems to normalize alcohol disrupted brain activity and reduce craving, but has shown mixed results. Some anti-convulsion medicines are being studied in clinical trials to reduce withdrawal, craving, and overall drinking ( Jupp & Lawrence, 2010 ).

Several additional drugs such as the psychostimulants have fewer medical treatment options. A vaccine that creates cocaine specific antibodies that sequester the cocaine molecules as they enter the circulatory system is in pre-clinical trials. One problem is that a higher dose of cocaine can still overwhelm the antibodies, and the vaccine does not help with other related stimulants ( Jupp & Lawrence, 2010 ). Further measures for deterring addictions are on the horizon, such as genetic testing. Identifying the genetic markers that identify those individuals who have physiological weaknesses for specific addictions may show promise if coupled with counseling and support.

Other technologic measures are designed to make the environment safer for the person who uses alcohol or drugs. These measures do not prevent the use of alcohol or drugs but protect both the user and innocent people from the effects of use. Passive restraints and air bags in automobiles are perhaps the best examples. Various devices have also been developed to prevent an intoxicated person from turning on the ignition of his or her automobile. Some states, such as Pennsylvania, have passed ignition interlock device legislation, requiring repeat DUI offenders to provide breath samples before their cars will be able to start ( Litchman, 2002 ). Fire-retardant or fireproof clothing, bedding, and furniture also protect users who pass out or fall asleep while smoking.

Many cities have established a “tipsy taxi” service for drivers who have had too much to drink. In Tallahassee, Florida, for example, the city operates a free taxi service available to anyone on major holidays, when overdrinking is traditionally a problem. In the same city, Florida State University offers a free chauffeur service to all its students on a year-round basis. Alcohol-related traffic fatalities have fallen since these services were introduced.

Many communities are providing free needles and syringes to intravenous drug users in an attempt to slow the spread of infectious diseases, such as AIDS. These programs have spread much faster in European nations, partly because of a more liberal attitude toward such prevention efforts and partly because the laws are more conducive to these approaches. Many cities, such as Melbourne, Australia, have locked boxes in public restrooms where used needles and syringes can be safely deposited.

However, in many communities in the United States, there is a feeling that providing free needles and syringes encourages drug use. In many states, needles and syringes are available only through a physician’s prescription. Some communities have attempted to get around this problem by educating intravenous drug users in methods of cleaning their equipment before using it again or sharing it with another user. Both San Francisco and New York City launched efforts to educate these drug users to “bleach their works” before state courts eventually allowed the distribution of needles and syringes.

The Harm Reduction Coalition was organized to promote the health of those who are impacted by drug use. It supports efforts to prevent further harm to those affected by drugs. Some of their programs include syringe access to prevent HIV and Hepatitis C. They have an overdose prevention component that includes information on how to help someone who has overdosed, such as teaching laypeople to administer naloxone to prevent death from an opioid overdose. In Illinois, the first naloxone distribution program in the United States reduced overdose deaths by a third in three years ( Harm Reduction Coalition, 2010 ). The coalition also supports treatment options such as pharmacological replacement therapies. Additionally, education is encouraged to reduce harmful interactions, such as between HIV medication and methadone, and safer use of drugs, such as safer injection techniques and early detection of deadly injection site infections. Although their practices have saved lives, they are controversial. For example, although U.S. President Barack Obama signed into law in 2009 removing a 21-year ban restricting federal funding for needle exchange programs, some states, such as Florida, still have laws that make it illegal to deliver drug paraphernalia if it is known that it would be used for illegal substances. Of the known 211 programs running syringe exchanges nationwide, it is estimated that half operate outside the law ( Adams, 2010 ).

Legislative, Regulatory, and Economic Measures

Legislation, judicial intervention, and administrative regulations regarding drug use can be employed to raise revenue, safeguard public health or morals, provide both political and economic rewards, and prevent drug use and abuse. This chapter discusses only the latter purposes. The others will be deferred until the next chapter, where the concept of regulation will be dealt with in considerably greater depth.

Throughout the eighteenth and nineteenth centuries, there were many local and state laws restricting the sale of alcohol, culminating in 1917 in national prohibition. Whatever the failings of this “noble experiment,” one of its primary purposes was achieved—a substantial decrease in the consumption of beverage alcohol ( McKim, 1991 ). Other legislation has controlled the hours and location of sale for alcoholic beverages, and there have been long-standing laws against serving alcohol to minors. These laws are also intended to reduce consumption, frequently among specific populations. Still other laws have placed restrictions on certain activities associated with drinking (gambling; nude dancing; driving a car, boat, or airplane; etc.) as a way of protecting the public from some of the side effects of drinking alcohol. So-called dram shop laws have been revived to make it illegal for bartenders and other servers to serve alcohol to obviously intoxicated persons. Several lawsuits and court decisions upholding server liability laws have impressed on tavern owners the need for better training of their personnel. Perhaps this desire to reduce liability will lead to a reduction of some alcohol problems ( Olson & Gerstein, 1985 ).

Regulation of other psychoactive drugs is much less complicated. In most cases, there is either no law restricting the use of a drug (e.g., gasoline, glue, and other inhalants) or it is simply illegal to use or possess it (heroin). However, in California, common substances utilized as inhalants, such as spray paint, are contained in locked shelving. In relatively few cases (marijuana), a drug may be illegal except for certain limited medical purposes. Regulation of most of these drugs came much later than for alcohol, however. Opiates were not made illegal until the Harrison Act of 1914. Although many states had prohibitions against its use, marijuana was not outlawed nationally until the Marijuana Tax Act of 1937. Recently, there have been many more drugs added to the list of controlled substances, but there is little evidence that these prohibitions have significantly affected drug trade or drug use. In fact, government attempts to limit the supply of drugs may have served mostly to drive up prices and increase the profits of drug dealers ( Currie, 1993 ).

Recent Legislation

On June 22, 2009, the Family Smoking Prevention and Tobacco Control Act, (U.S. Congress, Public Law 111-31, 2009), was signed by President Obama. As a primary prevention measure, this legislation increased taxes and included larger health warnings to discourage smoking. Additionally, cigarettes targeted to minors with fruity and other pleasant flavors were banned. The measure gave the FDA authority to regulate tobacco products, something anti-smoking groups had wanted for a long time. Manufacturers must now submit all ingredients including additives, amount of nicotine, and tobacco type to the FDA. They are also required to submit any research concerning their tobacco products. It is up to the FDA to act on each distinct ingredient ( U.S. Department of Health and Human Services, FDA, 2009a  &  2009b ). Additionally a Tobacco Products Scientific Advisory Committee now provides information on research on health and safety related to all tobacco products.

The No Child Left Behind Act of 2001,(P.L. 107-110, Title IV, Part A) was written with language that specifically encourages Safe and Drug-Free Schools (SDFS). The purpose was to provide support to “prevent the illegal use of alcohol, tobacco and drugs” (Sec. 4002). The act emphasized the need for coordinated efforts. It included funding availability of grants to improve school drug prevention programs, community-based drug prevention planning, programs and activities, and evaluation. Drug and alcohol programs that apply for the grants are required to demonstrate effectiveness. Although this legislation requires evidence-based prevention practices, research has shown that its impact varies. Of the 1,612 school districts sampled across the United States, nearly 12 percent did not receive SDFS funds, districts transferred more money out of SDFS (16 percent) than into the program (2 percent), and only a third of school districts reported using evidence-based curriculum. Additionally many of the evidence-based programs are too expensive for schools. Finally, a large majority of the state and local education agencies gave SDFS drug testing a low priority ( Cho, Hallfors, Iritani, & Hartman, 2009 ). Drug testing in schools does not show clear evidence of effectiveness as a prevention method and can be a source of several negative outcomes. For an overview of the legal issues, assumptions, evidence, and ethical comparisons of drug testing in both the U.S. and Australian schools see  Roche, Bywook, Pidd, Freemand, and Steenson, 2009 .

Health Warnings

Health warnings have been mandated for alcohol and tobacco products. As of 1989, everything from light beer to 100-proof vodka must carry a government warning concerning the risk to pregnant women of birth defects and the risk to everyone of impaired driving ability:

Government Warning: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems.

Tobacco products warn the user of a plethora of possible diseases. The impact of the warnings is unknown, but some argue that they may actually serve to protect the manufacturers from liability by providing the consumer with an adequate warning of potential risks involved in using the product.

Stricter Enforcement

All states have legislation prohibiting the sale of both alcohol and tobacco products to under-aged youth. While the enforcement of alcohol laws have been a great concern to local and state law enforcement authorities, only recently have they put much effort into enforcing the tobacco laws. In a study in California, minors aged 14 to 16 years attempted to purchase cigarettes in 412 stores and from 30 vending machines. They were successful in 74 percent of the stores and in 100 percent of the vending machines ( Altman et al., 1989 ). The situation may be changing, however. A large Maryland convenience store chain was convicted several years ago of routinely selling cigarettes to under-aged youths and was fined several million dollars ( “Chain Fined,” 1991 ). Today, laws relating to selling cigarettes to under-aged youth are being more strictly enforced by store owners because of government’s new sensitivity to adolescent substance abuse. However, purchases on the Internet may pose a greater problem.

The Tobacco and Alcohol Lobby

A major influence on legislation is the money that large corporations and lobbying groups provide to political campaigns at both the federal and state level. For example, during the 2007–2008 election cycle, the tobacco industry contributed over $2 million directly to federal candidates ( Tobacco-Free Kids Action Fund, 2010 ). The  National Institute on Money in State Politics (2010)  home page contains searchable records of state and federal contributions by corporation, candidate, political action committee, and/or ballot measure. During the 2007–2008 election cycle, the database showed the top companies that contributed to these state and federal campaigns, political parties, and ballot measure committees. The top three contributors that sell alcohol were the National Beer Wholesalers Association, Anheuser-Busch, and the Wine and Spirits Wholesalers of America. These three companies were responsible for over $14.5 million in donations. The top three contributors that sell tobacco were Philip Morris (Subsidiary of ALTRIA), Reynolds American, and U.S. Smokeless Tobacco. These three gave over $17 million to these state and federal entities during the same election cycle. Additionally, the Marijuana Policy Project, a group lobbying for medical marijuana and “sensible regulation” ( Marijuana Policy Project, 2010 ), gave over $3 million to candidates and ballot measures in 2008. On the other hand, groups such as the American Cancer Society donated over $1 million, and the American Lung Association only contributed $25, 000 ( National Institute on Money in State Politics, 2010 ). With financial forces like these at work, it is clear why legislation surrounding substances can become very complicated.

Workplace Regulations and Policies

Drug testing in the workplace has become a common detection and prevention effort. Federal Law now requires it for certain workers such as truck drivers and aircraft maintenance personnel ( U.S. Department of Transportation, 2009 ). In the transportation industry, research has shown that random drug testing coupled with peer-based substance abuse prevention reduced injuries by a third, resulting in millions of dollars saved in injury-related costs (Miller, Zaloshnja, & Spicer, 2007). As of 2004, all states authorized workplace drug testing, although some, like Oregon, only allow it if there is reasonable suspicion that an employee is under the influence ( ACLU, 2004 ).

Due to more convincing evidence of the negative effects of smoking, by the end of 1980s there had been restrictions placed on tobacco use in the workplace by 32 states and limits in other public places such as restaurants were found in 23 states. In addition, national restrictions were placed on smoking on airlines. Furthermore, smoking became almost universally prohibited in government buildings, public hospitals, and other health facilities. Tobacco companies have hotly contested these prohibitions, of course ( Mosher, 1990 ). By 1995, 46 states and Washington, DC, required smoke-free air in some public places. By 2000, The Centers for Disease Control and Prevention (CDCP) and the National Cancer Institute (NCI) had identified 1,238 state laws that focus on tobacco-control issues ( Farkas et al., 2000 ). The negative health consequences of environmental tobacco smoke are well documented. In 2009, the U.S. Institute of Medicine released a report concluding that even low level second-hand smoke causes an increase in cardiovascular diseases ( Institute of Medicine, 2009 ). Yet, as of 2010, only 27 states, Washington, D.C., and Puerto Rico had passed smoke-free laws that covered both restaurants and bars, but some local municipalities have passed their own bans. As of 2002, an average of 70.9 percent of workers were protected by non-smoking policies. Nevada and Kentucky still lag behind with only half of their workers protected from second-hand smoke at worksites ( Centers for Disease Control and Prevention, 2006 ).

Impaired Driving Prevention

Impaired driving prevention has been the subject of much legislation since the advent of the automobile. Research in the United States, England, and Scandinavia indicates that no one single approach to preventing DUI is preferable, but there is a constellation of measures that seem to be effective under various circumstances. These include vigorous enforcement of DUI laws, rapid application of sanctions, and clear-cut regulations that are widely publicized. Heavy fines appear to be about as effective as the revocation of driving privileges, mandatory “DUI schools,” and treatment.

Recent research indicates that tougher laws lowering the blood-alcohol concentration (BAC) level for impaired driving from 0.10 to 0.08 has been effective in reducing the proportion of fatal crashes involving alcohol. Also, the first eight states to adopt zero-tolerance policies for drivers under the age of 21 experienced a 20 percent reduction in nighttime fatal crashes among the 15- to 20-year-old age group ( Hingson, Heeren, & Winter, 2000 ). Some of the more controversial methods, such as roadblocks used to ferret out impaired drivers, have proven less effective( American Bar Association, 1986 ). Such methods also have been criticized as infringement on civil liberties, but so far the courts have generally allowed the practice to continue.

Understanding the need for empowering communities to influence the reduction of impaired driving, The National Highway Traffic Safety Administration and Community Anti-Drug Coalitions have joined efforts to create resources such as the Impaired Driving Prevention Toolkit, which gives facts and practical step-by-step instructions for community groups to be more effective in their DUI prevention efforts (2003). The toolkit includes information on how to build partnerships and work with service providers, legislators, law enforcement, and the media to produce change. It is becoming clear that legislative measures must be coupled with efforts of other groups, such as families and the community in order to be effective.

Economic Measures

The difference between legislative/regulatory measures and economic measures is primarily one of emphasis. The price of alcohol or tobacco, for example, may be a matter of a producer’s competitive strategy to capture a share of the market for its product. On the other hand, price also reflects federal and state legislation governing the rate of taxation for that product. Whether it happens because of company policy or government decree, the impact of a price increase or decrease on the consumer is likely to be much the same.

Several studies have indicated that the consumption of alcohol is relatively sensitive to price and that everything from cirrhosis to traffic fatalities could be reduced by increasing prices ( Olson & Gerstein, 1985 ). The increase in prices in the underground market after the passage of Prohibition in 1917 was undoubtedly one of the major factors in the dramatic decrease in consumption. The demand for tobacco products seems to be even more sensitive to price, especially among younger users. Increasing the taxes on cigarettes may be the most effective way of convincing novice users, such as adolescents, not to smoke ( Hopkins et al., 2001 ;  Mosher, 1990 ). When it comes to illicit drugs such as marijuana, there is little doubt that consumption increases as prices fall (Mosher, 1990). One of the few successes of the “war on drugs” may be in maintaining prices at a relatively high level, thereby deterring some potential users. The equation works the other direction as well. Research shows that teens with more spending money are significantly more likely to smoke and smoke more often ( Zhang, Camin, & Ferrence, 2008 ).

In addition to pricing policies, other economic measures include such items as allocating tax revenues from the sale of drugs to prevention programs (such as California’s Proposition 99), reducing insurance premiums for those who abstain from alcohol and tobacco, and tax incentives that discourage drug use. (Recent income tax reforms have disallowed the “three-martini” lunch.) It is not uncommon for government to use an economic measure as a subterfuge for prohibiting drugs. For example, the Marijuana Tax Act of 1937 placed a $100 per ounce tax on marijuana. Several states have drug tax laws that require those who buy or possess illegal drugs to purchase tax stamps for them. Failure to do so results in a tax law violation. These laws are often called Al Capone laws because of the prosecution of that notorious gangster, who sold bootleg liquor, under the tax evasion statutes.

Cost/Benefit Analysis

A larger, more comprehensive approach is necessary to evaluate preventive efforts. In 1999, the cost of drug abuse (including the federal drug control budget) was estimated at $110 billion annually ( ONDCS, 1999 ). Smoking-related diseases cost the United States approximately $97 billion annually in health care costs and lost productivity ( American Lung Association, 2002 ). The total estimated spending for health care services and treatment for alcohol abuse has been estimated at $26.4 billion a year. In addition, lost productivity and other social costs (such as DUI-related car crashes) bring the total to $184.6 billion in costs for alcohol abuse ( CADCA, 2008 ). It would therefore seem that prevention efforts focused on reducing initiation, harm, and relapse would be beneficial from a cost/benefit perspective.

In relation to program analysis,  Lille-Blanton and colleagues (1998)  recommend utilizing both cost/benefit analysisand cost-effectiveness analysis, or analyzing programs for the least expensive means of producing similar outcomes. The authors concluded that out of 3,206 studies, none had applied cost analysis to prevention programs. This is beginning to change, but quite slowly. Of the 58 evidence-based programs listed by SAMHSA (NREPP) as of January, 2010, only three mentioned outcomes related to cost/benefit criteria. All program listings did report the costs of implementing each program

The UN Office on Drugs and Crime states that for every dollar spent on high quality, research-based prevention programs for youth, nine dollars can be saved in the reduced costs resulting from crime, unemployment, and health issues ( UNODC, 2009 ). For example, the average financial cost for each additional year of life expectancy for those completing the program Not on Tobacco (N-O-T) was $442.65. This estimate ranged from $273.60 to $1,028.90 per life-year saved. The Strengthening Families Program has also reported cost-effective outcomes. Taking into account estimated intervention costs, the number of alcohol related disorders prevented by the program, the cost of alcohol use disorders for each case prevented by the program, and the average actual benefit of preventing one case of an alcohol related disorder, the researchers estimated that $9.60 is saved for every dollar invested. For each family, the net benefit is $5,923 ( NREPP, 2010 ). Given the high costs of treatment and law enforcement devoted to this problem, it is very important to fund prevention as a more economical alternative ( Woodward, 1998 ).

Family and Community Approaches

Most research shows us that no single prevention tool used in isolation is capable of causing even minimal changes in the actual incidence of drug abuse. As prevention theories have continued to be developed and subjected to empirical testing, we have learned that interactive and comprehensive programs using family, schools, religious systems, ethnic groups, and workplace interventions can be effective ( Belcher & Shinitzky, 1998 ;  Wyman, 1997 ).

Family programs engaging parents and children have demonstrated notable changes in both the addicted individual and the potential user ( Kumpfer et al., 1998 ). Although peers and the media can influence a child to begin using drugs, the number-one deterrent to drug initiation is parents who are involved in the child’s life. Children and teens whose parents discuss the media messages along with the stress in the child’s life and set rules and expectations have substantially lower risks of substance abuse ( Austin et al., 2000 ;  National Center on Addiction and Substance Abuse, 2010 . According to the Substance Abuse and Mental Health Services Administration ( SAMHSA, 2001 ), in 2000 only 7.1 percent of young people aged 12–17 who indicated that their “parents would strongly disapprove if they tried marijuana once or twice” had used an illicit drug in the past month. But 31.2 percent of the youth in that group that felt their parents “did not strongly disapprove” of their reported use of an illicit drug in the past month. Schools that provide interactive, repeated prevention measures have a significant impact on the initiation of drug use ( Belcher & Shinitzky, 1998 ).

In a thorough review of all the prevention programs listed on SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP), more than half of the listed programs involved parents, and over a third targeted families. One such program, Families and Schools together, is a program for multi-family groups to connect with each other, the schools, and communities. It uses an ecological approach with outreach to parents and children, includes multi-family group networking, and is facilitated by professionals and school personnel. Outcomes included reduced problem behaviors in the children and increased academic functioning ( NREPP, 2010 ). Another program encouraging family connections with the school, health service agencies and law enforcement is CASASTART, a “positive youth development program” that prevents substance abuse and violence among high-risk 8–13 year olds. Students who participate are less likely to use cigarettes, alcohol, marijuana, and hard drugs; have improved grades and attendance at school; and have fewer violent incidents ( CASASTART, 2010 ;  NREPP, 2010 ). The Strengthening Families Program created by Karol L. Kumpfer and associates ( Kumpfer, 1998b ) is another prevention program that has demonstrated long-term positive effects with families at high risk for drug use. It is a selective program that addresses the needs and skills of members of several racial/ethnic groups in relation to their families and communities. The program has been rigorously evaluated and refined, and has proven to have a positive impact on adults and children with the precursors of substance abuse.

On the community level, the  Institute of Medicine (2010)  has issued resources and specific recommendations for local-action groups to ban smoking in communities, improve interventions, and help implement tobacco regulation to reduce the tobacco problem in the future. Some recommendations include involving the media, law enforcement, health care, and insurance providers in supporting tobacco-free strategies. They also recommend policy action through legislatures, schools, and community agencies. The Community Anti-Drug Coalitions of America ( CADCA, 2009 ) is an organization that provides training and education and materials for over 5,000 anti-drug coalitions across the United States. Additionally, they advocate for these groups from the grassroots level to the national public policy arena. According to their 2008 annual report, 60 percent of CADCA-trained agencies bring new practice and/or policy changes to their communities. They tend to be more comprehensive in their approach and report higher levels of effectiveness.

Community Impact: Media

Both legislation and self-regulation have resulted in restrictions on the advertising of alcohol and tobacco products. Although the long-term effects of isolated advertising restrictions appear to be minimal ( Warner, 1979 ;  Willemsen & Zwart, 1999 ), the advertisements and promotions coming from the companies themselves can be quite effective in shaping behavior ( Villani, 2001 ). Industry standards prohibit the advertising of hard liquor on television, and although beer, malt liquor, and wine can be advertised, no one may be shown actually drinking it. There are strong arguments for restricting the advertising of these products in all media because they frequently appeal to young people, who are particularly susceptible to suggestions that wealth, success, and peer approval may be related to using the “right” kind of alcohol or tobacco product.

The multibillion-dollar tobacco settlement reached between the state attorneys general and the tobacco companies in 1997 resulted in an agreement by the tobacco companies to limit ads in newspapers and magazines with large youth leadership to black-and-white text only. Despite that agreement, however, tobacco companies continue to run large color ads in magazines such as People, Rolling Stone, Glamour, Vibe, and Mademoiselle ( National Center for Tobacco-Free Kids, 2001 ). Furthermore, tobacco products continue to be marketed specifically to racial and ethnic communities: Rio and Dorado to Hispanic Americans, American Spirit to Native Americans, and Pyramid and Heritage to African Americans ( Tobacco Control Research Digest, 1999 ). Tobacco advertisements represent 60 percent of advertising space for most African American newspapers, and three African American magazines (Ebony, Jet, and Essence) included 12 percent more cigarette advertisements than did other mainstream publications ( Tobacco Control Research Digest, 1999 ). Apparently, attempts to reduce smoking by limiting the advertising of tobacco products through the judicial process have not succeeded.

Ads for alcoholic beverages are well researched, slickly produced, and reinforced by well-organized promotions at the local retail level. After the Coca-Cola Company bought Taylor Wines in the late 1970s, it set out to promote the image of wine as a drink to be consumed regularly, rather than just on special occasions. Within a short time, the amount of advertising in the wine industry nearly doubled, partly because of Coca-Cola’s aggressive marketing techniques ( Olson & Gerstein, 1985 ).

Images such as the Budweiser “frogs” of the 1990s became readily recognizable even to children. In 1996, one year after the frogs hit the advertising market, children 9 to 11 years old became as familiar with these characters as they were with Bugs Bunny (Mediascope, 1997). During the 2009 Super Bowl, the top three most memorable ads with middle and high school students were beer ads ( Stewart, 2010 ).

Both the advertising and the brewing industries recently have come under heavy criticism for directing advertising campaigns at minority groups and young women. One example is the 2008 release of Virginia Slims “Purse Packs” that include thin cigarettes in teal and pink boxes to fit in a small purse. Another was the 2007 release of chic black and hot pink packaging of Camel No. 9 complete with promotional giveaways ( Campaign for Tobacco-Free Kids, 2009 ). Another example was the advertising of PowerMaster, a high-alcohol malt liquor, in media targeted toward low-income minorities ( “Real Brew-HaHa,” 1991 ). The tobacco industry also developed a new cigarette, Kool Mixx: House of Menthol, with a hip-hop theme. The marketing was complete with branded goody bags and CDs. R. J. Reynolds and the states of New York, Maryland, and Illinois entered into a settlement in October of 2004, calling for limiting any promotion of products that would target youths and a payment of $1,460,000 for programs aimed at youth smoking reduction and prevention ( DocStoc, 2010 ). Fortunately, public opinion and political pressure resulted in the removal of some products from the shelves. A very unusual marketing ploy by Kool cigarettes was introduced in Japan in 2007. They released a cigarette with a “powerball” of menthol in the filter that could be crushed to emit a strong menthol taste. The electronic looking packs came in plastic balls with a free metal case for matches. Looking more like a video game–related toy, the “powerball” was not contested in Japan ( Japan Trends, 2007 ).

The alcoholic beverage industry spends over $1 billion yearly advertising its products, and the ads continue to air more aggressively ( Nelson, 2001 ). For example, in 2002, NBC became the first network to drop a 50-year self-imposed ban on hard liquor advertising. The American Medical Association ( Hill, 2002 ) quickly responded with a statement urging ABC, CBS, and FOX television executives not to follow the NBC lead. The effect of advertising on actual use is a controversial issue on which outcome evidence is just beginning to build. A 2001 review of the literature on advertising concluded that (1) marginal changes in expenditures for alcohol advertising have little or no effect on total alcohol consumption, and (2) existing studies shed only minimal light on the relationship between advertising and market demand ( Tremblay & Okuyama, 2001 ). However, one national survey of 1,200 respondents aged 12 to 22 did find a moderately strong positive correlation between the amount of day-to-day exposure to ads for alcoholic beverages, on the one hand, and alcohol consumption and drinking in dangerous situations, on the other ( Federal Trade Commission, 1985 ).

Additionally, high quality, targeted advertising may be paying off for advertisers. For example, researchers from California found that beer advertisements that children liked also increased their likelihood of wanting to buy the brand. Elements that increased likability in youths were associated with humor and a good story, with ads such as the Budweiser Ferret-Lizard ads coming in first, and more serious ads like the Busch: Legacy of Quality ad coming in last (Chen et al., 2005). A longitudinal study of over 4,400 households in 24 American media markets conducted in 2006 found that the amount of alcohol advertising expenditures in youth-oriented media was related to greater youth drinking and steeper increases in drinking over time ( Snyder et al., 2006 ). Similar results have been seen with youth exposure to tobacco advertising. A longitudinal study found that when youths attending to cigarette advertising and utilizing tobacco product promotions such as bags, t-shirts, etc., reliably predict progression to established smoking even when other factors are taken into account ( Siegel & Biener, 2000 ). Evidence demonstrating that advertising increases consumption makes it clear why the American Academy of Pediatrics supports a “ban on cigarette and tobacco advertising in all media … including sports arenas,” and a restriction on alcohol advertising that allows only showing the product and no other characters ( American Academy of Pediatrics, 2006 ).

Substance Portrayal in Film and Television

Advertising is not the only way images of alcohol use are disseminated. In his study of Hollywood’s treatment of the alcoholic,  Denzin (1991 ) found 664 movies that used alcoholism as a major theme between 1909 and 1991. Many of those, such as Harvey and Arthur, depicted the main characters as “happy alcoholics” with no particular need to deal with their alcohol problems. More recent movies (Thank You for Smoking, Walk the Line, and Trainspotting) bring the viewer to a much more realistic appraisal of substances. Researchers studying the relation between movie exposure to alcohol and tobacco and subsequent long-term use and problems in a national sample of adolescents found very interesting results. Among 532 top box office hits over the preceding 5½ years, 83 percent contained alcohol use. Increased movie alcohol exposure was significantly associated with increased adolescent alcohol use over time. Additionally, it was also related to subsequent alcohol problems ( Wills, Sargent, Gibbons, Gerrard, & Stoolmiller, 2009 ). It was also calculated that each child could expect to be exposed to an average 594 movie smoking occurrences. Results showed that higher exposure to movie smoking was related to greater likelihood of smoking onset, even when a number of other factors were taken into account. The research also showed increases in positive expectations about smoking and more affiliation with friends who smoked (Wills, Sargent, Stoolmiller, Gibbons, & Gerrard, 2008).

Television exposure to substance use is high as well. The rate of alcohol consumption averaged 8.13 incidents per hour on the top 10 series and 2.25 per hour on the soap operas. Alcohol use was shown in an almost entirely positive context, with no indication of potential risk ( Greenberg et al., 1981 ).Researchers have also noted that on television, alcohol was consumed more than any other food or drink ( Mathios, Avery, Bisogni, & Shanahan, 1998 ). In research on music videos across five music genres (Adult Contemporary, Country, Rock, Rap, and Rhythm & Blues), 20 percent portrayed tobacco use and 23 percent contained alcohol use. Rap music had the highest proportion of tobacco and alcohol use, and rhythm and blues had the lowest ( DuRant et al., 1997 ).

In 1982, three alcohol-related tragedies rocked Hollywood. Two celebrities, Mary Martin and Janet Gaynor, were critically injured when a drunk driver crashed into their taxi. Next, William Holden died alone in his room because he was too drunk to know that he was bleeding to death. Finally, Natalie Wood, after drinking “a few” glasses of wine, slipped off the side of a boat and drowned. Not long after these events, one of the major networks televised a news series called The Hollywood Alcoholic. The result of this new realization of the dangers of alcoholism was an effort by a caucus of producers, writers, and directors to produce these guidelines for dealing with alcohol use on television and in the movies ( Gerstein, 1984 ):

1. Try not to glamorize the drinking or serving of alcohol as a sophisticated or an adult pursuit.

2. Avoid showing the use of alcohol gratuitously in those cases in which another beverage might be easily and fittingly substituted.

3. Try not to show excessive drinking without consequences or with only pleasant consequences.

4. Try not to show drinking alcohol as an activity that is so normal that everyone must indulge. Allow characters a chance to refuse an alcoholic drink by including nonalcoholic alternatives.

5. Demonstrate that there are no miraculous recoveries from alcoholism; normally, it is a most difficult task.

6. Don’t associate drinking alcohol with macho pursuits in such a way that heavy drinking is a requirement for proving one’s self as a man.

7. Portray the reaction of others to heavy alcohol drinking, especially when it may be a criticism.

There have been some notable efforts by the media since then to incorporate these guidelines into their programming. For example, the TV series Mercy has focused on the problems experienced by its chief character and her alcoholic parents. The movie Requiem for a Dream graphically illustrated the most debilitating consequences of drug abuse, and it also won rave reviews from the critics. The movie Traffic dealt comprehensively with the intricacies and consequences of the illegal drug trade. It was unique in addressing drug issues among many levels of government, within families, and across cultures. The well-publicized incarceration of Robert Downey, Jr., and the drug-related deaths of celebrities Heath Ledger and Michael Jackson have also brought a great deal of the entertainment industry’s attention to the problem of illicit drugs and the misuse of prescription drugs. Public service announcements regularly warn young people and their parents about the dangers of alcohol, tobacco, and drug abuse, and urge parents to discuss these dangers with their children at home.

At the same time, however, it is still easy to find the gratuitous portrayal of alcohol use in the media. Research conducted by  Roberts and colleagues (1999)  found that of the 200 most popular movies of 1996 and 1997, alcohol and tobacco appeared in more than 90 percent of them and illicit drugs appeared in 20 percent. Many times, these movies graphically portrayed the preparation and/or utilization of these substances. Very few of the films specified motivations for use, and fewer than half portrayed short-term negative consequences.

It is the National Association of Broadcaster’s position that alcohol use should be de-emphasized on television. The truth is that the rate of drinking on television still seems to be much greater than in real life. According to one estimate, a person under the legal drinking age will be exposed to approximately 3,000 acts of drinking during a year of television viewing ( Greenberg et al., 1981 ). Is it any wonder that young people’s T-shirts sport such popular themes as “It’s Only a Drinking Problem if I’m Sober” and “Avoid Hangovers, Stay Drunk”? Obviously, television and the other mass media are not entirely to blame, and they have taken certain steps to improve programming. But, as  Anderson and colleagues (2009)  have concluded in a thorough review of 13 longitudinal studies of over 38,000 young people, exposure to media and commercial communications on alcohol increases the likelihood that adolescents will initiate alcohol use and drink more if they are already using. Therefore, more should be done by the media industry to decrease exposure and provide the proper messages to young people about the use of alcohol.

Product Placement

For many years, tobacco companies have had arrangements with movie studios for product placement, or showing the use of their products in movies. Documents released during the state of Minnesota’s lawsuit against the tobacco industry showed arrangements between tobacco giant Philip Morris and the makers of 11 hit movies, all of which had large box office sales to youth ( Youth Media Network, 2001 ). Although there are some restrictions on advertising alcoholic beverages, there are no restrictions on the use of alcohol by actors in television programs or films. Consumption of alcoholic beverages is frequent in TV programs, but, the incidence of actors smoking has decreased.

Despite protestations by the tobacco companies that they no longer paid for product placement after a voluntary movie industry ban in 1988, a study of “tobacco scenes” between 1990 and 1996 yielded some very interesting results. While the total number of tobacco scenes per movie rose slightly, the number of tobacco scenes with the film’s star increased dramatically ( Youth Media Network, 2001 ). A more recent study of tobacco presentations in 1,769 films between 1991 and 2008 showed overall reductions in tobacco incidents in movie, but total tobacco incidents on screen remains above late 1990s levels. Tobacco brands have increased on screen, with Marlboro accounting for75 percent of brand display in 2008 ( Titus, Polansky, & Glantz, 2009 ). One company remains a shining example in this data. A large decrease, “36% of the drop in total tobacco impressions delivered to moviegoers in the last four years, industry wide” ( Titus, et al., 2009 , p. 6), can be attributed to the October, 2004, Disney Depiction of Smoking in Movies policy. The policy explains that due to awareness of “recent studies suggesting a relationship between the depiction of smoking in movies and increases in adolescent smoking,” they are no longer depicting smoking in movies carrying the Disney brand, strongly discouraging “the depiction of smoking in [Touchtone] movies primarily marketed to youth,” and discouraging smoking, where appropriate and practical, in those movies produced outside the United States where Disney is a coproducer. While seeking to limit smoking, they do, however, allow for the “creative vision” of those involved in the productions where smoking is important to the movie ( The Walt Disney Company, 2006 ). However, other companies are not as helpful. About 75 percent of films released by Universal continue to include tobacco use ( Titus, Polansky, & Glantz, 2009 ). Updated weekly,  Smoke Free Movies (2010)  posts the top grossing movies’ and DVD rentals’ tobacco status as “Promotes smoking,” “Smoking with negative consequences,” or “Smoke Free.” On the week of January 4, 2010, for example, half of the top grossing movies promoted smoking and half were smoke free. Although all of the movies specifically directed at young children were smoke free, major motion pictures with cross-over appeal such as Avatar depict smoking without any negative consequences. Unfortunately, attempts to curtail youth from buying substances by restricting advertising may be undone by the frequent images of those substances in television programs and film.

Community Impact: Sports

Most Americans at some point have participated in and/or have become a spectator in sports. Participation in sports has been known to be a protective factor against certain substance use in teens, but it can also be a source of stress for highly competitive athletes who enhance their ability to succeed in their sport through the use of performance enhancing substances. Steroid use came to the front of U.S. awareness in U.S. President George Bush’s January 2004 State of the Union address tackled prevention in sports:

To help children make right choices, they need good examples. Athletics play such an important role in our society, but, unfortunately, some in professional sports are not setting much of an example. The use of performance enhancing drugs like steroids in baseball, football, and other sports is dangerous, and it sends the wrong message—that there are shortcuts to accomplishment, and that performance is more important than character. So tonight I call on team owners, union representatives, coaches, and players to take the lead, to send the right signal, to get tough, and to get rid of steroids now. ( Bush, 2004 , para.56)

Professional athletes may be tempted to use steroids for competitive, financial, and societal gains. But, currently, major organizations such as the U.S. National Football League (NFL) are directly addressing substance abuse by their athletes. The NFL Player Development Program addresses many prevention issues surrounding substance abuse. In the four day Rookie Symposium run by NFL “League personnel, expert facilitators, trained professionals, active players, and former players are involved in delivering a program specially designed to give incoming players detailed information about what they may face during their NFL careers” ( National Football League, 2009 ). The life-skills workshops include substance abuse and DUI training, which consists of the policy, the danger and consequences of substance abuse. Additionally, according to a spokesperson from the corporate NFL Player Development Program (Anonymous, personal communication, August 31, 2009), rookies are required to take an eight-week Conduct Management Program. One unit focuses on substance abuse prevention and policy. Each year thereafter, all clubs require mandatory substance abuse “refreshers.” All players are offered a Players Assistance benefit which provides four free counseling sessions. Finally, most clubs have a program to prevent recidivism.

Empirically-based programs are emerging specifically focusing on student athletes and substance abuse prevention. The ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) is a school-based, team-centered program that attempts to deter the use of substances and encourage healthy lifestyles in middle and high-school female athletes. Young women who participated in the program demonstrated less diet pill, amphetamine, and steroid use. They also exhibited significant reductions in long-term cigarette, alcohol, and marijuana use. Additionally, they practiced healthier eating habits ( Elliot et al., 2006 ;  NREPP, 2010 ). A comparable program for young male athletes is ATLAS (Athletes Training and Learning to Avoid Steroids). It targets young men involved in sports to prevent substance abuse and to promote a healthy lifestyle. Athletes participating in the program were significantly less likely to initiate steroid use than were the students who did not participate in the program. The participating athletes also reported less long-term alcohol and illicit drug use ( Goldberg et al., 2000 ;  NREEP, 2010 ).

Despite these successful efforts, performance enhancing “doping” is present in all major athletics. Before and during the Beijing Olympics, for example, 47 athletes were caught doping. The International Olympic Committee, however, has maintained a strong anti-doping code to prevent as much drug use as possible ( Wochenschr, 2009 ). After the 2007 reports that the dozens of professional U.S. baseball players were found to have used steroids and several athletes were banned from the Tour de France due to doping, some debated whether performance enhancing drugs would become commonplace to the point that they are accepted ( Katz, 2008 ). Many would argue that doping for sports is wrong due to the deleterious consequences on health and the fact that it is cheating. Although substance use, including steroids, remains prevalent in athletics, several organizations are having a positive impact on the issue.

Community Impact: Social Networks

Positive social networks across ecological systems are known to act as major protective factors against negative substance abuse outcomes in teens and adults ( Mayberry, Espelage, & Koenig, 2009 ;  Garmendia, Alvarado, Montenegro, & Pino, 2008 ). Recognizing their importance, the American Recovery and Reinvestment Act of 2009 included grant funding for studying social networks and their influence on groups at high risk for negative health behaviors including substances ( National Institutes of Health [NIH], 2009 ). A popular medium for networking is the Internet. It contains cutting-edge resources for social networking, as well as advertising and marketing, with advantages and disadvantages in relation to substance abuse prevention. The Internet can be a place of easy access to prevention information and support for those attempting to remain drug free for the first time or following prior substance abuse. On the other hand, it also facilitates the acquisition of prescription drugs, tobacco, and alcohol for minors and those in recovery from substance abuse issues. For example, according to a study in the Journal of the American Medical Association ( Ribisl, Williams, & Kim, 2003 ), cigarette vendors on the Internet did not comply with laws governing tobacco sales in stores. Many sites did not screen for age, and others lacked the Surgeon General’s warning. Of vendors located in the United States, minors successfully received cigarettes 93.6 percent of the time when using a credit card and 88.9 percent of the time when using a money order. Age was not verified for any of the deliveries of 1,650 packs of cigarettes to adolescents. It is difficult to adequately address this issue. Even if laws are enacted in the United States to regulate these sales, enforcement would become almost impossible, as only 88 of the 1,808 sites screened were located in the United States. Other illicit drugs and questionable prescription drugs are marketed on the Internet. In one week, a typical spam folder from a user who had never bought prescription drugs online contained over 30 requests to buy pharmaceuticals from dubious sources. Some of these advertised drugs, such as Adderall, Percocet, Vicodin, and Imovane, were controlled substances and/or drugs not available in the United States as of 2010. The Drug Enforcement Administration (DEA) attempts to close illegal internet operations to prevent easy access. In 2002, they had an “unprecedented takedown” of an Internet-based “date-rape” drug-trafficking operation that involved more than 80 U.S. cities. Finding ways to reduce the advertisements and access to these types of operations is extremely difficult, but new technology in the field of computer forensics can now track Internet traffic paths even when the messages have been password encoded and deleted. Experts are continuing to use innovative techniques to track and eliminate illegal operations (Eric K. Thompson, Chairman & CTO, AccessData Computer Forensics, personal communication, January 22, 2010).

File sharing on social networking sites such as You Tube and Facebook has impacted prevention efforts in remarkable ways. For example, one local prevention effort, Faces of Meth is a project of the  Multnomah County Sheriff’s Department in Oregon (2005) . Deputy Bret King and the Multnomah County Classification Unit created a collection of before and after mug shots of individuals who had been booked more than once and had records of methamphetamine use in all cases. In addition, he interviewed meth users and used the photos and interview information to create the Faces of Meth prevention program. In a personal interview with the Web Administrator for the Multnomah County Sheriff’s Department, Sarah Mooney, the Faces of Meth website had over 625,000 hits by the beginning of 2010 and had sold 700 copies of their CD.

However, in a thorough search of the Internet, it was found that the project is actually impacting millions more viewers worldwide. For example, the Faces of Meth is featured on major websites such as  The Partnership for a Drug-Free America (2010) . These photos and those with a similar theme have become part of a natural networking prevention effort. For example, a YouTube video entitled “Drug Abuse Pictures Before and After” using the Multnomah pictures has had over 1.5 million views ( marajade619, 2006 ). It is most popular with young male viewers. Comments on the site range from the silly to advocating other drugs to real stories of the impact the photos have. For example one comment stated, “this was inspiring, I was heading in that direction but now I know for sure that it wasn’t too late for me” (klownofdestruction, 2010). Another YouTube site using meth prevention material originating from the  Montana Meth Project (2010)  had over seven million views as of January, 2010 ( FalseInternetName, 2006 ). And, the messages from similar sites such as Meth; Not Even Once ( NaomiDreamStudios, 2009 ), a school project, are reaching worldwide viewers. Some messages actually reach out to help others. For example on the same site, “a lot of kids, thank God, are not actually stupid enough to try it nowadays. ive been addicted since i was thirteen. every day i watch these videos trying to find a reason to get clean. still trying. if your thinking about trying it, please message me and ill give you thirty reasons off the top of my head not to. it took one hit to pull me under” ( breanavirgilio, 2009 ).

Although some posts demonstrate that these types of informational sharing have prevented some from using, the threads become a discussion for all types of viewpoints—some supporting the use of “soft” drugs, some wanting policy change, others just commenting on how sad it is, or making jokes of it all. Interestingly, since 2004, the year “Faces of Meth” was made available to others involved in methamphetamine prevention efforts, methamphetamine use in teens has steadily declined ( NIDA, 2009 ). It would be very interesting to conduct research to see how these shared files have impacted behavior on a wide scale. The Multnomah County Sherriff’s office isn’t waiting. They are continuing their efforts with a broader focus on drugs other than meth, with their new project From Drugs to Mugs.

As discussed, the incorporation of a wider ecological view including family and community factors has been the biggest recent advancement in prevention research. Incorporating the environment in which the person interacts has a sizable impact on the results of prevention programs both long and short term. Although the outlook is promising, environmental impacts from media and social networking may also be reducing planned intervention effects. Much more research is needed to explore these macro levels of intervention.

Spirituality and Religious Factors

Spirituality and religious factors may be very helpful in deterring substance abuse. A study addressing spirituality made several interesting observations. Adults who never attend religious services are almost “twice as likely to drink, three times more likely to smoke, and more than five times likelier to have used an illicit drug other than marijuana, almost seven times likelier to binge drink, and almost eight times likelier to use marijuana than those who attend religious services at least weekly” (Foster et al., 2001). The effect for teens is also significant. Teens who do not consider religious beliefs important are almost three times more likely to drink, binge drink, and smoke; almost four times more likely to use marijuana; and seven times more likely to use illicit drugs than adolescents who strongly believe that religion is important. A limitation of this study is the heavy Judeo-Christian background of the sample. However, a southwestern study conducted with a more ethnically diverse population, including Native Americans, demonstrated findings in a similar direction ( Hodge, Cardenas, & Montoya, 2001 ). In a review of over 105 articles addressing spirituality and substance abuse,  Chitwood, Weiss and Leukefeld (2008)  found in 99 of the 105 articles that one or more dimensions of religiosity or spirituality were significantly associated with reduced risk of substance use or misuse. Over 75 percent looked at teens and college students; more than half studied organized religious practices rather than spirituality in general, and the large majority looked at alcohol and marijuana use rather than other drugs. Despite these limitations, it is clear that spirituality is an important component of prevention.

Based on evidence that spirituality is protective against substance abuse, spiritually-based prevention programs are now emerging in greater numbers. For example, spiritual growth appears to be associated with the benefits of Alcoholics Anonymous, which acts in a secondary and tertiary prevention manner ( Zemore, 2007 ). In addition to the traditional Alcoholics Anonymous broad-based spirituality, some programs focusing on more specific religious aspects of substance abuse prevention are beginning to gain momentum. For example, Celebrate Recovery is a Christian-based program based on the twelve step model, but with steps reflecting a specifically biblical focus. A typical evening will include dinner, a large group worship with a person sharing the spiritual aspect of their recovery story, prayers, and small support group breakout sessions. It originally focused on alcohol at Saddleback Church in Riverside, California, and has expanded to serve other “hurts, habits and hang-ups.”Meeting in churches or community centers, its focus is providing long-term support for individuals striving to remain substance-free. It also offers concurrent support groups for families of those working through issues of recovery. Over 500,000 people have completed the program worldwide ( Saddleback Resources, 2009 ).

Another program, Art of Living, is a yoga based Sudarshan Kriya and Pranayam deep breathing, chanting, and meditation technique that has been used for many health- and stress- related issues, including tobacco addiction. Researchers reported that at a six month follow-up, 21 percent of those who participated in the Art of Living Program had remained tobacco free. This is comparable to those who take the drug Bupropion to remain tobacco free and much better than the 11 percent who take a placebo ( Art of Living, 2009 ;  Kochupillai et al, 2005 ).

Another program that has targeted spirituality has been the Natural Connection Program. For this program, youths were involved in deep discussions rooted in Native American cultural values. In addition to sessions conducted in the classrooms, the participants attended presentations from traditional healers and spiritual leaders from eleven different native traditions. These elders also conducted spiritual and healing ceremonies ( Navarro, Wilson, Berger, & Taylor, 1997 ).

Cultural Factors

Approaches addressing the specific needs of racial/ethnic subgroups have demonstrated positive responses from their respective communities. For example, Chipungu and fellow researchers (2000) reported higher rates of satisfaction and perceived program importance in African American youth exposed to Afrocentric prevention programming, compared with other prevention approaches. Strong racial/ethnic identification has been identified as a significant predictor of drug attitudes ( Belgrave, Brome, & Hampton, 2000 ). However, confounding variables of community factors must be addressed, including poverty and neighborhood characteristics.  Delva and colleagues (2001)  found that prevalence of drug use among minority mothers dropped by 40 percent in black mothers compared to white mothers, once the negative effects of poverty and drug availability in the neighborhood were held constant.

Programs are emerging which focus on the needs of specific cultural groups and those at high risk due to difficult community circumstances. An example of an empirically-based program utilizing a multifaceted ecological approach as a prevention tool is Project Venture. Created by the National Indian Youth Leadership Project, the outdoor experiential curriculum specifically works with Native American youth to build self-efficacy, resilience, and decision making skills, which, in turn, facilitates resistance to alcohol, tobacco, and other drugs ( National Indian Youth Leadership Project, 2008 ). The program specifically incorporates older peer mentors, family involvement, classroom, community service, cultural values, and spiritual awareness in these 5th-8th grade youths, resulting in significant differences in substance use over time between participants and control groups ( Carter, Straits, & Hall, 2007 ).

Another example, Storytelling for Empowerment, uses the arts to directly address Latino teens at high risk for substance abuse living in communities with high rates of poverty and availability of drugs. Cognitive decision making, positive cultural identity, and resilience models are the basis of stories, plays, artwork, and discussions to reduce high-risk behaviors. Participants demonstrated less abuse of alcohol and marijuana over time when involved in at least 20 contact hours with the program, but hard drug use was not affected ( Nelson & Arthur, 2003 ). Another innovative culturally targeted program, H2P, is a drug and HIV prevention program with a hip-hop based curriculum created for urban African American middle-school students. It has shown preliminary evidence of changes in risk perception of drugs ( Turner-Musa, Rhodes, Harper, & Quinton, 2008 ). These programs are promising, but much more research is needed in this area.

Chapter 8 Regulating Drugs and Their Consequences

One of the major obstacles to the successful prevention and treatment of chemical dependency problems is that there is no clear understanding of the etiology of drug abuse or dependence at the level of individual pathology (see  Chapter 2 ). From a clinical perspective, therefore, it is difficult (some would say impossible) to match an individual’s treatment needs with a particular treatment modality that is best suited for those needs. Experts do know, however, that there are a number of social, cultural, and environmental factors that influence an individual’s probability of using drugs. Unfortunately, treatment plans are often developed as if chemical dependency were only an individual phenomenon, frequently ignoring important systemic causes and consequences. Most of the previous chapters focused on clinical issues; this chapter turns to some important public policy issues related to drug availability, use, and treatment. We will continue and expand the discussion, begun in  Chapter 7 , regarding the types of collective action that society may employ in controlling drug use.

We also will continue the debate over the deregulation of certain drugs within the context of broad public policy issues. Public policies regarding drug use and addiction include much more than the legality of manufacturing, selling, and using drugs, however. Public policy is concerned with controlling or limiting the use of specific drugs, restricting use to specific segments of the population (such as adults, cancer patients, etc.), avoiding the misuse of drugs, enhancing governmental revenues through the collection of taxes on drugs (especially alcohol), and protecting domestic drug producers from foreign competition. The use of marijuana for medical purposes continues to be a hotly debated issue, and we will attempt to cover various perspectives on this issue. Finally, we will turn to one of the most troubling policy issues regarding drug use: what to do about the relationship between drugs and crime. The “war on drugs” is in its fourth decade, and the end is not in sight.

Sociocultural Influences on Public Drug Policy

Public policies regarding drugs vary widely throughout the world. They have also varied widely within nations during the last few centuries. Until the early part of the twentieth century, very few drugs were strictly regulated by any government ( Bean, 1974 ). Public policies that are now common in modern Western societies cannot be considered historical norms ( White, 1991 ).

Variations between cultures depend partly on historical accident: Peyote grew in the American Southwest, heroin in Asia, and cannabis from the Middle East to India. Beverage alcohol is the most nearly universal psychoactive drug. As locally produced drugs were spread by international trade, the culture of the importing nation had a profound impact on public policy toward these new drugs. When it was first introduced to Europe, tobacco was used as a medicine in some countries and as a mild stimulant in others. In Russia, it was used as an intoxicant by means of deep and rapid inhalation ( White, 1991 ).

Drugs associated with ceremonial and religious use are generally treated differently from other drugs. Alcohol commonly was used by a great many people in ceremonies and rituals, often to the point of intoxication. Until very recently, these same people rarely used alcohol outside of these rituals and ceremonies. The same can be said of marijuana use in some areas of India. Where use of a drug is a very old, traditional practice, such as opium use in Arab countries, it is usually restricted to the adult male population ( Rubin, 1975 ).

Religious beliefs and practices may either inhibit or reinforce the use of particular drugs. Psychoactive drugs were frequently viewed in traditional societies either as a gift from God or as “the devil’s brew.” The native residents of both North and South America used hallucinogenic drugs as a part of religious rituals. Indeed, Native Americans in the United States are still fighting for the right to use peyote legally in ceremonies sanctioned by the Native American Church. The cactus plant from which the drug is obtained is believed to be a gift from God to man. On the other hand, the strong religious injunctions against the use of alcohol in many Muslim countries severely restrict its use. This ban was decreed by the prophet Mohammed and still carries the force of law in countries such as Saudi Arabia ( White, 1991 ).

Sociocultural differences are also found in conceptions of the role of government regarding the health and welfare of its citizens, and these different conceptions influence public policy responses to the use of drugs ( Moore & Gerstein, 1981 ). Thus, Sweden, Norway, and Finland introduced retail liquor monopolies as a way of limiting consumption. The former Soviet Union had a complete state monopoly on the production, distribution, and sale of alcohol, although those functions are now mostly privatized. In the United States, several states have adopted a monopoly distribution system for distilled spirits but not for wine and beer. Other states allow competitive retailing but control the hours and location of sales. Some states allow beer and wine sales in supermarkets, convenience stores, and gas stations, whereas other states restrict such sales to liquor stores. Communities in states with local option laws may simply prohibit the sale of alcoholic beverages. Even so, some restaurants and clubs allow patrons to bring and consume their own liquor.

Economic and Political Factors

Why do societies decide to regulate some drugs, prohibit other drugs, and ignore some drugs altogether? In many cases, the production and supply of the entrenched drugs—such as alcohol, nicotine, and caffeine—are sources of wealth and power ( White, 1991 ). Permissive policies toward other drugs may threaten business. Since coffee could not be grown in Europe, it was necessary to import it. The Germans saw this as a threat to their beer industry, and the English imposed heavy taxes on coffee as a way of protecting tea produced in British colonies.

It is easy to understand why U.S. distillers and brewers may oppose the legalization of other drugs. Depending on the degree to which newly legalized drugs could be substituted for alcohol, they could stand to lose a great deal of money. On the other hand, some say that the U.S. tobacco industry is prepared to produce marijuana cigarettes in the event that cannabis is legalized ( U.S. Congress, 1988 ). This new market might take up some of the slack resulting from declining cigarette sales.

Economic factors also have an impact on the enforcement of existing drug laws. It would be counterproductive for the tobacco industry to favor strict enforcement of the age limitation for the purchase of cigarettes when all their future customers, not to mention the fastest-growing segment of their current market, are under 18 years of age.

The socioeconomic status, political position, and race of drug users also must be considered. Heroin and crack cocaine use are still regarded as being most common in African American ghettoes. Most experts agree that these drugs are least likely to be legalized. When marijuana was perceived to be a drug used mostly by African Americans, Hispanic Americans, and a few eccentric literary figures and musicians, there was not much support for its legalization. Now that hundreds of thousands of middle-class college students have used marijuana, there is much more support for its decriminalization—even in otherwise conservative states ( Galliher, McCartney, & Baum, 1974 ).

Changes in Drug-Use Patterns

The types of drugs used and the manner of their use within a society vary over time. A society with few or no restrictions in one historical period may have comprehensive regulations of most drugs during another time ( Morgan, 1981 ). Traditional societies tended to have available a rather narrow range of drugs, and they were frequently used in religious rituals and ceremonies, such as Native Americans’ use of peyote. This type of limited use was not viewed as a cause for alarm. Eventually, international trade brought new types of drugs to practically every nation. New drugs became a threat because they were used recreationally, their effects were not known, and their users were regarded as deviant. This called for regulation.

Changes in the manner of use of a single drug also have resulted in pressures for regulation and control. Oral administration or smoking of drugs such as opium and heroin present fewer threats to the users’ health and safety than does intravenous injection. Oral administration of OxyContin was consistent with medical practice, but crushing it for inhalation is strictly for recreation. Little thought was given to drinking small amounts of cocaine in soft drinks such as Coca-Cola; the consequences of this type of use represented no more of a threat to the user than the chewing of coca leaves by South American aborigines. Snorting cocaine brought more immediate results, but it was not regarded as truly dangerous until users began to inject a soluble form with a hypodermic needle. Intravenous use not only produces an instantaneous high, but it also brings the risk of addiction and the additional hazards of hepatitis, HIV infection, and other diseases. Finally, the discovery of a new form of smokable crack cocaine brought even greater risks of addiction. The use of cocaine itself seems no more an issue than the form of administration.

The Nature of Drug Control

The most obvious function of drug control, and the primary reason cited by lawmakers, is to decrease the amount of a particular drug that is used. In some cases, such as heroin, the goal is complete prohibition. In other cases, such as cocaine, the goal may be to limit use of the drug to medical practice. In still other cases, such as alcohol, governments may allow general use by adults but seek to limit the amount used by monitoring price controls, taxes, number of outlets, and the hours of sale.

The Harrison Narcotics Act of 1914 was primarily a labeling and registration act, and its purpose was to restrict the distribution of narcotic drugs to physicians and pharmacists. Prior to this act, access to opium derivatives was not officially restricted. After 1914, distributors had to register with the U.S. Treasury Department.

Most legal drugs are taxed. Since they are widely used commodities in any modern economy, governments have discovered that they can be a significant source of tax revenue. In most cases, the tax is imposed primarily for the purpose of raising revenue, but taxes on drugs are also used to regulate trade in one way or another. Such was the case of Britain’s tax on Jamaican rum that was destined for other colonies and thus competed with English gin. Alcoholic beverages were first subjected to federal taxation in the United States in 1791, and a liquor excise was the first internal revenue law enacted by Congress under the Constitution. As late as 1907, these revenues constituted 80 percent of all federal internal tax collections ( Moore & Gerstein, 1981 ).

Drug taxes almost always have a dual effect of decreasing consumption and raising revenue. Sometimes the revenues from taxes on a drug are only incidental to the primary purpose of the tax, prohibiting use of the drug. The Marijuana Tax Act of 1937 used a tax to outlaw marijuana. Marijuana approved for medical use was taxed at$1 per ounce. Marijuana used for other purposes was taxed at $100 per ounce. Few people would voluntarily pay taxes on drugs that are being sold or used illegally ( McKim, 1991 ).

Both the amount of revenue raised and the success of the tax in curbing consumption depend on the degree of price elasticity of the product being taxed. The elasticity of any particular drug depends on a number of factors, such as (1) the degree to which another drug may be substituted for it, (2) the availability of the drug, (3) the addictive power of the drug, and (4) the cost of the drug, including taxes. It is generally agreed that taxes on alcoholic beverages diminish their consumption ( Moore & Gerstein, 1981 ) but that distilled spirits are less price elastic than beer ( Ornstein, 1980 ). In other words, a tax on distilled spirits would result in a smaller decrease in consumption than the same tax on beer. Beer is more frequently consumed as a beverage and could be replaced by tea, coffee, soft drinks, and the like. The relative elasticity of illicit drugs is less well known.

Assumptions Underlying Regulation

A number of important assumptions underlie any government’s efforts to control drug use. One is that drug use produces victims ( ONDCP, 2001 ). Victims may be the actual users of drugs or they may be innocent bystanders—those who passively inhale cigarette smoke, those maimed or killed by drunken drivers, or those whose family life is destroyed by drug use. Others argue that use of drugs is a victimless crime that has no major adverse consequences for the rest of society, but this view is not consistent with governmental regulation.

Closely related to this is a second assumption that governments are responsible for enhancing the general welfare. A nation with a large proportion of drug users would be at an economic disadvantage in the world market because of reduced work output and the need to divert resources to handle the health and welfare needs of users. In regulating drugs as a way of promoting the general welfare, government walks a fine line between benefiting the majority of its citizens and encroaching on the individual liberties of a few. This potential conflict frequently appears when governments declare smoke-free workplaces, prohibit the possession of alcoholic beverages in a public park, subject vehicles to searches, or use drug-sniffing dogs at airports.

Governments find it just as difficult to distinguish nonproblem from problem drug use as distinguishing use and misuse (see  Chapter 1 ), but they do it anyway. Those drugs that are perceived not to cause problems (such as caffeine) are subjected to few controls. Those that are deemed to be troublesome but are impossible to prohibit because of widespread public use and acceptance, and because they are easily produced (such as alcohol), are tightly regulated. Those perceived to be the most problematic (heroin, cocaine) are generally banned.

These divisions between problem and nonproblem use are somewhat arbitrary, and the reasons for regarding drugs as acceptable or not are largely historical rather than pharmacological. For example, alcohol produces marked changes in behavior, has dangerous physical effects, and is powerfully addictive. It is highly unlikely that the United States would ever completely legalize any other drug with such undesirable consequences ( White, 1991 ).

Regulation of Alcohol

Alcohol is tightly regulated in most countries and banned in a few. It remains an extremely popular drug, despite its adverse consequences and the problems of addiction associated with its use. Because of its special position in most societies as a historically controlled but legal psychoactive drug, it deserves special attention in this chapter.

The Lessons of Prohibition

Although it is widely believed that the Eighteenth Amendment to the U.S. Constitution, which prohibited the production and sale of alcohol, was a failure and that it demonstrated once and for all the futility of governmental attempts to legislate morality, this is not a completely accurate account of the effects of Prohibition ( Levine, 1980 ). This legislation failed in the sense that it bred contempt and open defiance of law and order, and it also fostered the growth of organized crime. No one denies that the Volstead Act was widely violated and that smuggling, moonshining, and speakeasies all thrived during the Prohibition era. On the other hand, there is considerable evidence that the consumption of alcoholic beverages declined considerably, especially among the working class. The most reliable indicators of heavy consumption—including acute alcohol overdose mortalities, liver cirrhosis, and hospital admissions for alcoholic psychosis—dropped well below their pre-Prohibition levels ( Warburton, 1932 ). These declines were related to the price of alcohol, which tripled or quadrupled in parts of the nation after the Eighteenth Amendment took effect ( Olson & Gerstein, 1985 ). It can be expensive to deal in the underground economy!

According to  Moore and Gerstein (1981) , there are three principal lessons of Prohibition that should be remembered in any future attempts to regulate the supply of beverage alcohol:

1. Drinking customs in the United States are strongly held and resistant to frontal assault. It is well beyond the will or capacity of government ever to eradicate the customary demand for alcoholic beverages.

2. A criminal supply network emerges—if not instantly, then within a few years—if production and sale of alcoholic beverages are outlawed. The prices and extent of this criminal supply depend on the degree of public support for the law and the resources devoted to law enforcement.

3. The quantity of alcohol consumption and the rates of problems varying with consumption can, however, be markedly reduced by substantial increases in real prices and reductions in the ease of availability.

The well-remembered lesson of Prohibition is that an abrupt legislative decree banning beverage alcohol will not work in U.S. society. In fact, the failure of Prohibition may be responsible for the tendency of many of those interested in alcohol problems to “disassociate themselves from the taint of temperance” ( Room & Mosher, 1979–80 , p. 11). An equally important lesson, but one that seems to have been forgotten, is that regulation can reduce consumption and alcohol-related problems.

Current U.S. Policies

Today, all states in the United States set a minimum age for the legal consumption of alcohol and prescribe penalties for retailers who knowingly sell to underage customers. Some states assess penalties even when a retailer mistakenly sells alcohol in good faith to a minor with fake identification. Under pressure from the federal government, including the threat of withholding highway trust funds, the minimum age has shifted back to 21 years. All states also impose special excise taxes on alcoholic beverages, and most have restricted advertising, hours of sale, and credit sales.

Beginning in the 1930s, 18 states chose to create state or county monopolies to control both wholesale distribution and retail sales of distilled spirits. The remaining states adopted licensing systems in which state regulatory agencies are empowered to license wholesalers and retailers and to promulgate and implement other rules and regulations regarding beverage alcohol sales.

Although the Twenty-First Amendment, which repealed Prohibition, left the “dry” option open to individual states, all of them now permit alcoholic beverage sales in at least part of the state. In most cases, dry counties are predominately rural areas, and they tend to be concentrated in the South. Even there, however, drinking usually is allowed in certain lodges, fraternal organizations, and private clubs.

Taxes and Price Controls

A fundamental law of economics is that as the price of something goes up, people will generally buy less of it. Thus, as prices for alcoholic beverages rapidly rose during Prohibition, demand decreased ( Olson & Gerstein, 1985 ). The same effect in reverse may also be partly responsible for the increase in per capita consumption that has occurred since the last major increase in federal taxes in 1951. Between 1967 and 1984, the real price of liquor dropped by almost one-half. One reason for this dramatic decrease in price was the fact that the federal excise taxes were not based on the price of the beverage but instead were tied directly to volume. Thus, the tax on an expensive quart of vodka is the same as on a cheap quart of vodka. Some critics have argued that the most important feature of federal policy in alcohol abuse prevention during the past several decades is the failure to index excise taxes on liquor to the consumer price index ( Cook, 1984 ).

In addition to taxes, many state governments also influence alcohol prices through fair trade laws and, in monopoly states, by administrative fiat. States with liquor monopolies may still set prices by decree in state-owned liquor stores, but the courts have eliminated price fixing by the liquor industry through fair trade laws. The method used to set prices may make a great difference to the state treasury, but it matters very little to the consumer. A price increase that arrives through taxation, price fixing, or administrative decree is all the same to the customer at the checkout stand. All three methods equally affect demand for the product.

Perhaps the most comprehensive analysis of the connection between alcohol prices, consumption, and alcohol-related problems was conducted by Philip  J. Cook (1984) . His examination of changes in liquor tax increases over a 15-year period demonstrated that even relatively small changes in prices influence not only the consumption of alcohol but the most serious health effects as well. Similar decreases in consumption, heavy drinking, and alcohol-related problems due to price increases also have been noted in other countries ( Popham, Schmidt, & DeLint, 1976 ).

An especially important question is whether a decrease in overall consumption within a population affects the drinking patterns of heavy drinkers. The pioneering work of  Ledermann (1956)  and subsequent studies by several others confirm that even a significant proportion of problem drinkers in any population will reduce their consumption as overall consumption is reduced ( Skog, 1971 ). Some have suggested that regulation aimed at prevention of problem drinking might be more effective if specific taxes were levied on particular beverages favored by heavy drinkers, such as cheap brands of fortified wine ( Olson & Gerstein, 1985 ). However, this may just encourage switching to other alcoholic beverages. This argument also favors keeping the tax tied to the volume of alcohol sold, rather than the purchase price, since the former approach would have a greater impact on alcoholics, especially poor alcoholics who customarily purchase the cheaper types and greater quantities of alcoholic beverages.

Even though taxes on alcohol constitute a relatively small proportion of governmental budgets, governments closely consider the implications of these taxes on their revenues. This is especially true during serious budget crises. U.S. President George H. Bush’s promise of “no new taxes” was quickly amended in 1990 to allow consideration of increases in both alcohol and tobacco taxes—so called “sin” taxes. Governments are most certainly aware of the danger of raising taxes to such a high level that revenues may actually decrease from a reduction in sales. As long as the alcoholic beverage lobby still exerts any influence in legislative circles, taxes are unlikely to rise to such levels. Still, if governments have no choice but to raise income taxes or “sin” taxes, and if the amount of additional revenue needed is moderate, the latter are politically less volatile.

There are a number of other mechanisms by which government may influence the price and thereby control demand for alcohol. Between 1986 and 1992, tax laws subsidizing alcohol consumption by allowing tax deductions for beverages purchased with business-related meals were gradually eliminated. Another example is the long-standing practice of selling alcoholic beverages at greatly discounted prices on U.S. military bases, a practice that strongly encouraged drinking by both uniformed and civilian employees and their families. Fortunately, the military establishment has realized that many problems were caused by selling cheap alcohol, and current policies have changed this practice.

Control of Distribution

In addition to taxation and monopolistic price controls, government can do much to regulate the consumption of alcohol by controlling its distribution. It can do this by adopting and implementing policies regarding the number, size, and location of outlets, hours of business for package stores and bars, advertising practices, and the minimum legal drinking age.

The matter of licensing retailers is generally a function of state and local governments. A number of earlier studies have attempted to determine the effect of outlet density on alcohol consumption, but there appears to be no relationship ( Popham, Schmidt, & DeLint, 1978 ). A quasi-experimental study in Ontario compared sales to residents of two cities located some miles apart, both of which were served by a package store located in one of them. Per capita sales were roughly equal for these two cities, despite the considerable differences in accessibility ( Popham et al., 1978 ). Outlet density may be more a result than a cause of demand in communities that treat alcohol sales as a proper function of the free market ( Smart, 1977 ).

Monopoly distribution systems also do not seem to have any appreciable effect on alcohol sales. In the former Soviet Union, for example, consumption is high and alcoholism is a major social problem ( White, 1991 ). A comparison of states in the United States that have monopoly distribution systems with those that allow private competition showed no difference in levels of consumption or indicators of alcohol-related health problems ( Popham et al., 1978 ).

There is little evidence that restricting the hours of sale reduces consumption. In fact, a study of changes in the hours of sale over a 25-year period concluded that “Sunday closing” laws (sometimes called blue laws) and earlier closing hours had the opposite effect: more sales ( Hoadley, Fuchs, & Holder, 1984 ). However, other changes in availability have been related to increased consumption. These include a gradual easing of restrictions on alcohol sales since World War II. Liquor-by-the-drink is now available in almost every large city, wine and beer are routinely sold in grocery stores and convenience stores, mixed drinks are available in restaurants, and sporting events often realize as much profit from the sale of alcohol as from the sale of tickets.

Blose and Holder (1989)  found a significant increase in alcohol sales and alcohol-related automobile accidents immediately after North Carolina adopted liquor-by-the-drink. When Idaho, Maine, Virginia, and Washington made wine available for sale in grocery stores, wine consumption rose significantly ( MacDonald, 1985 ). Anyone who has ever attended a professional baseball or football game where alcoholic beverages are sold can attest to their popularity. Consumption at sporting events has become such a problem in some communities that local officials have imposed beer-free games on the fans. Several major stadiums no longer sell any beer after the seventh inning of major league baseball games—with no significant effect on attendance.

The effect of increased availability on consumption is not peculiar to the U.S. culture. One study of the liberalization of alcohol laws in Finland showed a remarkable doubling of consumption in just seven years. The Alcohol Act of 1969 abolished restrictions on sales in rural areas, lowered the drinking age, and permitted retail shops to sell beer with a higher alcohol content. By 1975, the Finns were drinking 156 percent more beer, 96 percent more spirits, and 87 percent more wine. (Another curious fact is that Finnish drivers already had a higher rate of driving under the influence [DUI] than other Europeans before the liberalized liquor laws [ Olson & Gerstein, 1985 ]. This happened despite a lower rate of drinking—indicating, perhaps, that enforcement was stricter in Finland.)

Drinking Age

Other than Prohibition, perhaps no other area of alcohol policy has been so emotionally charged as the minimum legal age for purchasing and consuming alcoholic beverages. The most common legal age for consuming alcohol throughout the world is 18. There are currently 12 nations (including Germany, Portugal, and Poland) that have a minimum drinking age of 16 years. Another 17 nations have no minimum age at all ( Alcohol Problems and Solutions, 2010 ). Minimum age restrictions are based on the assumption that alcohol use is more harmful for young persons than it is for adults. There always has been some variation in this age in the United States, but historically most have used the age of 21 as the minimum age for unrestricted purchases. This continues to be a point of contention among the young, since they can vote and are eligible for military service at age 18. Between 1970 and 1973, 24 states reduced their minimum drinking ages, reasoning that 18- to 21-year-olds should have all the rights and responsibilities of adulthood ( Olson & Gerstein, 1985 ).

During that period, an enormous amount of research was conducted on the impact of lowering the minimum age of purchase. One conclusion stood out quite clearly: Lower drinking ages were associated with significant increases in the rate of automobile crashes among young people ( Public Health Service, 1987 ). Estimates of the increase in fatality rates were found to be 7 percent among those states that had dropped their minimum ages from 21 to 18 years of age ( Cook & Tauchen, 1984 ).

Partly because of this evidence, 15 states raised their minimum drinking ages back to 21 between 1975 and 1982. Among 13 of these states that were studied, automobile crashes were reduced from a minimum of 14 percent to a maximum of 29 percent ( Arnold, 1985 ). Another study of 9 states that raised their minimum drinking age between 1975 and 1979 found a 41 percent decrease in nighttime single-vehicle fatalities ( Williams, Zador, & Karpf, 1983 ). With such convincing evidence in hand on the effect of minimum age legislation, Congress passed the Minimum Drinking Age Act of 1984 that reduced federal highway funds for any state that did not raise its minimum drinking age to 21 years by 1986. Despite the outcry on college campuses and frantic lobbying by the alcohol lobby, most states complied by the deadline. Louisiana held out until its highway system could no longer survive without federal funds. It appears that the national minimum age of consumption will remain at 21.

One of the other arguments against a lower minimum age is that it makes it just that much easier for 16- and 17-year-old students who have 18-year-old friends to obtain alcohol. (Remember, a majority of high school seniors will be 18 years old before their graduation.)

The National Highway Traffic Safety Administration (NHTSA) credits state laws that rose the legal drinking age to 21 with preventing about 1,000 traffic deaths annually. Many states have reduced the maximum blood-alcohol concentration (BAC) level for drivers under age 21 to 0.02 percent, and this has reduced nighttime fatal crashes in this age group by 16 percent ( NIAAA, 1996 ). Nevertheless, almost two-thirds of 16- to 19-year-old drivers who had positive blood-alcohol concentrations in 1998 were higher than 0.10 percent. More than 15 percent of them tested at more than 0.20 percent ( Yi, Stinson, Williams, & Dufour, 1999 ).

Driving Under the Influence

In most situations, the possession and use of alcohol by adults is completely legal. However, when a legally intoxicated individual attempts to drive an automobile, a crime has been committed. Driving under the influence (DUI) or driving while intoxicated (DWI) is a criminal offense in all 50 states and the District of Columbia. (Most states also have laws against having any kind of open container of alcohol in a moving motor vehicle.) Progress has been made in reducing alcohol-related crash fatalities, falling from 43.6 percent of total crash fatalities in 1986 to 30.5 percent in 1998 ( Yi et al., 1999 ). Advances in technology (automobile engineering, airbags, etc.) and stricter public policies are thought to be responsible.

All states now have a BAC maximum level of .08 percent for adult drivers. Many have “zero tolerance” policies (usually .02, but sometimes .00) for drivers under the age of 21 ( APIS, 2010 ). Sometimes called the blood-alcohol level (BAL), this figure is determined by the ratio of the weight of alcohol to the volume of blood grams per 100 milliliters (G/100ml). In states with per se laws, it is an offense to drive with a BAC at or above the specified value. A defendant may be convicted on the basis of chemical test evidence alone. Moreover, a driver may be charged with a DWI or DUI at a level lower than the state’s per se standard if impairment can be shown. Other states use a particular BAC as a presumptive standard, allowing the defendant to introduce evidence that he or she was not, in fact, impaired at the prescribed limit ( APIS, 2010 ). The question of how effective these laws are in influencing the rate of drunken driving is still unsettled. Some moderately persuasive evidence does suggest that effectively enforced drunk driving laws deter drunken driving and reduce the accidents and fatalities associated with them.

The most thorough study of drunk driving laws is possibly that of the British Road Safety Act (RSA) of 1967. This act provided a per se BAC limit of 0.08 percent, and the first conviction resulted in a mandatory one-year license suspension. The new law was also preceded by a great deal of publicity.  Ross’s (1973)  evaluation of the RSA found a 23 percent decline in auto fatalities, a decline in other auto injuries, and a decline in BAC levels of injured drivers—all within the first few months after implementation. Unfortunately, these improvements gradually flattened out and then began to rise by the end of 1970. The explanation for these events was that the well-publicized passage of the RSA convinced many drivers that the risk of arrest and punishment would be much higher than it had been. Although they were deterred from drinking before driving and from driving after drinking, law enforcement did not markedly increase the certainty of either detection or punishment, and drivers gradually returned to their old habits as this became known to the public.

In the United States, an evaluation of 35 alcohol safety action programs between 1970 and 1977 concluded that 12 of the programs had produced a decrease in nighttime auto fatalities, an accepted indicator of drunken driving ( Levy, Voas, Johnson, & Klein, 1978 ). Nevertheless, there continues to be a great deal of controversy over DUI laws. In most states, a common result of a DUI conviction is the administrative suspension of the driver’s license. No one could deny the logic (and perhaps the justice) of this method. However, police report that a very large proportion of DUIs involve drivers whose licenses already have been suspended for previous DUI convictions. One reason the courts cite for not strictly enforcing DUI laws is that they impose “new and heavy demands on courts, incarceration facilities, and probation services” at a time when the criminal justice system is already overflowing with more supposedly serious crimes ( ABA, 1986 , p. 101). Prosecuting attorneys frequently feel that tough mandatory sentences for drunk drivers are ineffective and may actually raise public expectations to unrealistic levels ( ABA, 1986 , p. 105). Organizations such as Mothers Against Drunk Driving (MADD) and Students Against Driving Drunk (SADD) have reacted by bringing even greater pressure for tougher sentences, especially for drunk drivers who kill or injure other people. Such pressure has resulted in much political posturing by state and local politicians but few effective solutions. Some judges have resorted to bizarre sentences such as mandating a convicted drunken driver to place a “Drunken Driver” plate or tag on his or her automobile. Needless to say, other family members who drive this automobile suffer needless embarrassment.

Another popular approach in dealing with drunken drivers is the sobriety checkpoint. The typical procedure is for local police to set up unannounced roadblocks along certain routes and stop vehicles, sometimes at random, to check for indications of alcohol impairment. Earlier studies questioned their effectiveness, but recent evidence indicates that they may reduce alcohol-related crashes.  Shults et al. (2001)  reviewed 23 studies and concluded that following the implementation of checkpoints, crashes involving alcohol dropped by 18 percent and fatal crashes dropped by 22 percent. Although a number of states have prohibited sobriety checkpoints as an unconstitutional invasion of privacy under state law, the U.S. Supreme Court upheld their legality in  Michigan State Police Dept. v. Sitz (1990) . The American Civil Liberties Union (ACLU) continues to criticize the use of sobriety checkpoints, and there will probably continue to be additional challenges in state courts.

Like drug use and possession, drunk driving lacks the usual criminal motives of gaining property or harming another person. DUI offenses are also unique in that a physical test (breathalyzer, blood analysis, etc.) is used and compared against a state standard to determine whether a crime has been committed. Drunk-driving offenses are also frequently handled administratively rather than judicially through driver’s licensing regulation. This means that a driver’s license can be suspended without any judicial safeguards. In most states, when drivers receive their licenses, they agree to take a breath or blood test if they are stopped on suspicion of driving while intoxicated. Refusal to take a test upon request is a violation of the licensing agreement and can result in automatic suspension or revocation of the license through an administrative process. Most states have such sanctions ( APIS, 2010 ).

According to the National Household Survey on Drug Abuse, one in ten Americans aged 12 or older had driven under the influence of alcohol at least once in the preceding 12 months. Among young adults aged 18 to 25 years, the rate was 19.9 percent ( SAMHSA, 2001 ). Between 1970 and 1986, arrests for drunk driving increased by223 percent. DUI arrests peaked in 1983, with1.9 million persons arrested ( BOJS, 1988a ).From 1986 to 1997, the number of people arrested for DUI fell 18 percent, from 1.8 million to 1.5 million ( BOJS, 1999 ). By 2008, DUI arrests had fallen again to 1.1 million ( BOJS, 2010b ). The decline in drunk-driving arrests is attributed partially to the aging of licensed drivers. Fifty-four percent of licensed drivers were over the age of 40 in 1997, compared to 46 percent in 1986. In both years, the older the driver over age 21, the lower the rate of DUI arrests.

In interviews conducted with DUI offenders, about half admitted that they had consumed the equivalent of at least 12 beers or 6 glasses of wine prior to their arrest. The average BAC was 0.24 among jail inmates and 0.19 among probationers. Six percent of prison inmates and 12 percent of jail inmates said that they had been previously sentenced for DUI five or more times ( BOJS, 1999 ).

Insurance/Liability Laws

Public policy is sometimes intended to indirectly affect the consumption of alcohol through such measures as the regulation of insurance rates. Drivers with DUI convictions may face higher insurance premiums, and in some cases, they may be unable to purchase automobile insurance. Since many of these drivers will continue to drive without insurance, these laws may actually be harmful to the larger population. There is no evidence indicating that higher insurance premiums have actually reduced consumption.

Another indirect measure involves server liability, or dramshop laws. In 35 states, commercial establishments that serve alcoholic beverages are civilly liable to those who experience harm or injury as the result of an intoxicated or underage person’s irresponsible use of alcohol ( Wisconsin Bar Association, 2010 ). The typical dramshop law imposes civil liability for damages caused by an establishment’s serving alcohol to “visibly intoxicated or underage customers” ( ABA, 1986 , p. 107). (Criminal liability may also be attached when a minor is involved.) The courts also have held that even without a dramshop law, civil liability can be imposed on a tavern under common law ( Rappaport v. Nichols, 1959 ). One result of these laws has been the provision of better training to servers to help them learn how to recognize and “cut off” a customer who is intoxicated and to see that such a customer gets home safely. Some communities offer training programs for servers on methods of referring problem drinkers to appropriate treatment services.

Decisions in a number of states have extended common law liability from commercial establishments to social hosts who provide alcohol to their intoxicated or underage guests ( Kelly v. Gwinnell, 1984 ). Eleven states have laws specifically extending liability to social hosts for intoxicated adults, and 30 states hold them liable for intoxicated minors ( Wisconsin Bar Association, 2010 ). There have been few studies of the impact of dramshop or server liability laws on alcohol consumption and related phenomena.  Wagenaar and Holder (1991)  found that liability lawsuits in Texas caused significant changes in alcohol servers’ practices, resulting in fewer people driving while intoxicated and fewer vehicle crashes involving injuries.  Holder et al. (1993)  found that in states where servers have a relatively high level of exposure to liability, there was more publicity regarding liability, alcohol servers were more aware of liability, there were fewer low-price drink promotions, and more servers regularly checked customers’ identification.

Control of Illicit Drugs

Public policies regarding illicit drugs have not reached the degree of specificity that is found in policies regarding alcohol use. The primary debate surrounding illicit drugs is whether it is possible to control their use through law enforcement. The current failure of public policy to deal with the drug problem is the logical outgrowth of policies pursued by the federal government over the past decade. Since the election of U.S. President Ronald Reagan in 1981, federal policy has been much more concerned with preventing recreational drug use than with helping habitual users. During Reagan’s first term, funding for drug treatment fell by almost 40 percent, adjusting for inflation ( Massing, 1992 ). The budget for the so-called war on drugs continued to rise, however. In 1998, 1.6 million Americans were arrested for drug law violations ( FBI, 2000 ), and nearly one in four persons imprisoned in the United States was imprisoned for a drug offense. The number of persons incarcerated for drug offenses (458,131) that year was almost as large as the entire prison and jail population was in 1980 (474,368) ( Justice Policy Institute, 2001 ). Between 1980 and 1997, the number of people entering prison for violent offenses increased by 82 percent; for nonviolent offenses, 207 percent; and for drug offenses, 1,040 percent ( Justice Policy Institute, 2001 ).

The approach chosen by the U.S. President George H. Bush administration was one of zero tolerance. This approach emphasized law enforcement toward the end of completely eradicating illegal drugs, and it appeared to be based on the following assumptions:

1. If there were no drug abusers, there would be no drug problem.

2. The market for drugs is created not only by availability but also by demand.

3. Drug abuse starts with a willful act.

4. The perception that drug users are powerless to act against the influences of drug availability and peer pressure is an erroneous one.

5. Most illegal drug users can choose to stop their drug-taking behaviors and must be held accountable if they do not.

6. Individual freedom does not include the right to self- and societal destruction.

7. Public tolerance for drug abuse must be reduced to zero ( Inciardi & McBride, 1989 ).

This policy meant that possession of even the smallest amounts of illicit drugs could result in the seizure and confiscation of an individual’s automobile, home, or other property. Some saw this as a serious threat to civil liberties.

Although still woefully inadequate, the George H. Bush administration did increase treatment funding by 50 percent to $1.6 billion. At the same time, the administration continued its preoccupation with casual middle-class drug use, not with addiction or habitual use.

The candidates in the 1992 presidential race, George H. Bush and Bill Clinton, seldom mentioned the drug issue, and there would have been little more interest in the 1996 election if there had not been a report indicating an increase in adolescent drug use. The Republican Party seized this issue, despite the fact that this trend had actually started during the Bush administration.

The nation’s first “drug czar” (appointed by George H. Bush), William Bennett, developed a strategy of seeking out and punishing casual, nonaddicted users. He also insisted that all drugs were equally pernicious ( Zimrig & Hawkins, 1992 ), a somewhat incongruous philosophy for a two-pack-a-day smoker! The next drug czar, former Florida Governor Bob Martinez, shied away from the public spotlight and made few changes in Bennett’s approach. Barry McCaffrey, the next drug czar, was a retired Army general and seemed determined to continue a zero-tolerance policy. Drug policy during the Clinton administration changed very little.

The major drug issue in the 2000 presidential campaign was whether candidate George W. Bush had ever used cocaine—a question he steadfastly refused to answer ( Abadinsky, 2001 ). Fewer changes in drug policy have been noted in the U.S. President George W. Bush administration, despite promises to take an even tougher approach. John P. Walters, the top deputy in the drug office of the current Bush administration, was appointed as drug czar by George W. Bush. Walters strongly advocated mandatory minimum sentences that would lock up drug users as well as street-level dealers ( “Record of Bush Nominee,” 2001 ). Although U.S. President Barack Obama’s drug czar, Gil Kerlikowske, called to an end of the “war on drugs,” there has been little change in federal enforcement efforts, and President Obama opposed the recent referendum in California to legalize marijuana ( Shapiro, 2010 ).

Recipients of public assistance programs have not fared well in the war on drugs. While the eviction of drug users/pushers from public housing projects has received a great deal of attention, other policy changes have actually been more far reaching. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 allowed states to ban public assistance (TANF and food stamps) to individuals with drug-related felony convictions, and it also permitted states to drug test welfare recipients and sanction those who test positive ( CSAT, 1998 ). For the 20,000 Americans who are disabled due to drug addiction or alcoholism, the Contract with America Advancement Act of 1996 did the following:

· Prohibited Supplemental Security Income (SSI) Disability Benefits

· Prohibited Social Security Disability Benefits (SSDA)

· Eliminated Medicaid eligibility

· Eliminated Medicare eligibility

· Required substance abuse treatment referral only if drug addiction and/or alcoholism is secondary to another disability and the recipient is unable to manage own benefits. ( CSAT, 1998 )

These punitive measures are especially hard to understand in view of the acknowledged fact that welfare clients must have substance abuse treatment in order for welfare reform to succeed.“For many current welfare recipients, substance abuse may pose the largest single obstacle in their ability to secure and keep jobs” ( CSAT, 1998 , p. 1).

Other nations have chosen different strategies. For example, The Netherlands has legalized the use of certain drugs, such as marijuana. The Netherlands has been the European leader in so-called harm-reduction approaches, but Switzerland, Spain, Italy, Germany, and the Czech Republic are also trying similar approaches ( McNeece, Bullington, Arnold, & Springer, 2001 ). Although Great Britain has a reputation for legalization, its approach to controlling illicit drugs really is one of harm reduction through methadone maintenance and needle/syringe exchange programs.

Many experts feel that the United States is rather myopic in considering other options. All but six states still prohibit the distribution of hypodermic needles and syringes without a prescription, making it impossible to operate a legal needle/syringe exchange program ( Abadinsky, 2001 ). A 1995 report by the National Academy of Sciences found that needle exchange programs reduced the spread of HIV/AIDS ( Leary, 1995 ), and in 1997, the American Medical Association endorsed the concept of needle exchange programs ( Abadinsky, 2001 ). Nevertheless, fear of retaliation by conservative members of Congress led U.S. President Bill Clinton to continue the federal ban on such programs, despite evidence that they did not lead to increased drug use ( Stolberg, 1998 ). President Obama expressed support for needle exchange programs during his campaign, but reversed his position after being elected. Congress, however, removed the ban on federal funding for needle and syringe programs from the 2010 budget. Whether federal funds will ever find their way to these programs is still an open question ( International Harm Reduction Association, 2010 ). In the United States, efforts to control illicit drugs have been hampered by the great degree of fragmentation of federal, state, and local drug enforcement programs. A report from the Comptroller General indicated that the supply and demand of illicit drugs have remained relatively constant despite the massive increase in federal drug control efforts. In fact, he seriously questioned the ability of governmental efforts to regulate illegal drugs in the absence of “factual information about which anti-drug programs work best” ( U.S. General Accounting Office, 1988 , p. 2). It is the recognized failure of antidrug enforcement policies that gave rise to the current debate on legalization of illicit drugs.

According to Dale Masi, an expert on employee assistance programs, the legalization of illicit drugs signals “the inevitability that use will increase.” Masi testified before Congress that this approach

“cannot be reconciled with ethical principles because it would be implemented with recognition of the increased personal and social destruction connected with drug abuse that would result. We, as a civilized society, are responsible for preventing disease and destruction, not spreading them.” ( U.S. Congress, 1988 , p. 137)

This view is not accepted by all the experts, however. A New York State Senator, Joseph Caliber, proposed the legalization of all drugs. His plan was intended to eliminate criminal drug trafficking by allowing the sales of currently prohibited drugs in the same place and manner as alcohol. Similar restrictions on minimum age for purchase, hours of sale, location of stores, and so on would apply to drugs sales just as to current alcohol sales ( U.S. Congress, 1988 ).

Other testimony favored various compromise proposals, such as the legalization of the less harmful forms of illicit drugs. These advocates all favored the legalization of marijuana, and some favored legalizing certain forms of cocaine (coca leaves) and opiates (smokable opium) ( U.S. Congress, 1988 , p. 27). Compromise proposals frequently advocate some degree of decriminalization for particular drugs rather than complete legalization. This approach sometimes suggests a civil rather than a criminal penalty for the use or possession of a controlled substance. On other occasions, it suggests that no penalty be attached to use but that sales be subjected to criminal penalties. This leaves users in the awkward position of being legally entitled to use a drug but having no legal means to obtain it. The argument for legalization or decriminalization seems to be gaining acceptance, even among conservative politicians and writers. A major portion of an issue of the National Review was devoted to critiques of the war on drugs ( “War on Drugs,” 1996 ), and articles in the Journal of the American Medical Association have advocated decriminalization ( “Change of Heart,” 1994 ). These are other hopeful signs of change in U.S. drug policies—at both the state and federal levels. The state of Indiana repealed a provision that required a mandatory 20-year sentence for anyone caught with as little as three grams of cocaine—about the size of three Sweet-and-Low packets. A criminal justice reform bill was passed in Louisiana, which gives judges more discretion in sentencing drug offenders ( Ryckaert, 2001 ). Proposition 36 took effect on July 1, 2001, in California, diverting low-level, nonviolent drug offenders from the criminal courts to treatment ( Drug Policy Alliance, 2002 ). In a more recent development, more than 80 percent of the voters in Oakland approved a referendum to tax marijuana sold in the city’s dispensaries, a move also backed by the city council ( CNN, 2009 ). This is viewed not just as a revenue-raising measure for cash-strapped city government, but as a step toward normalizing the sale and use of marijuana.

On the federal level President Obama’s first budget proposal allocated some $64 million to rehabilitation programs such as drug courts, making it more likely for users to get treatment rather than incarceration. Attorney General Eric Holder has also slowed down the Justice Department’s raids on state-approved medical marijuana dispensaries. Finally, the “drug czar,” former Seattle Police Chief R. Gil Kerlikowske, is on record as not favoring hard-line drug policies ( Horwitz & Jamieson,2009 ), although there has been little significant change in actual enforcement activities.

The “War on Drugs”

U.S. President Richard Nixon was the first president to declare a “war on drugs.” He did this in 1971 as he also introduced stronger criminal penalties for drug dealers and proposed a rapid expansion of drug treatment facilities, especially those specializing in heroin addiction ( Besteman, 1989 ). Subsequent presidents continued this effort, with each promising to increase the war effort against drugs. Drugs have been less of an issue in the last three presidential elections, however.

The war on drugs was simply a continuation of the policies espoused in the Harrison Act in 1914, in which the federal government relied on a variety of approaches to reduce both the demand for and the supply of illicit drugs. The major changes are seen in the massive amount of funding for law enforcement, the perceived seriousness of the problem of drug abuse, and the advanced technological strategies for controlling drugs. Americans now use Bell 209 assault helicopters, Navy EC-2 and Air Force AWACS “eye-in-the-sky” aircraft, “Fat Albert” surveillance balloons, “Blue Thunder”high-performance Coast Guard vessels, and NASA satellites to fight the drug war. The war analogy may seem appropriate in halting the operation of large drug cartels, but it seems inappropriate when it comes to dealing with other aspects of drug abuse. The war analogy seems especially inappropriate regarding efforts to prevent or treat drug abuse by the nation’s children ( Gustavon, 1991 ).

For more than a decade, critics of the war on drugs have declared it “a losing battle,” “almost an afterthought,” and “hype from an Administration and Congress eager to justify the expenditure of billions of dollars for law enforcement” ( Shannon, 1990 , p. 44). According to  Doweiko (2002) :

As should be obvious by now, the government’s effort to solve the drug abuse problem though law enforcement/interdiction has been a failure. Of course this does not stop law enforcement officials from trumpeting the successes of the past year from hinting that, for just a few billion dollars more, it may be possible to eliminate the problem of recreational drug use in the United States. (p.  438 )

These “get-tough” efforts may sound good to the public, but no serious student of drug policy is encouraged by the efforts at law enforcement in the attempt to reduce illegal drug use. Although during the Clinton administrations, there were fewer highly publicized drug eradication efforts in nations such as Colombia, the war on drugs changed little. The Bush administration endorsed a continued policy of tough law enforcement and eradication efforts, as signaled by the appointment of the current drug czar and continuing operations in Colombia and other drug-producing Latin American countries. The Obama administration has softer rhetoric, but little change in actual enforcement policies.

Forfeiture Laws

State civil asset forfeiture laws have been growing in popularity with law enforcement agencies as a tool in dealing with illegal drugs over the last three decades. These laws allow law enforcement agencies to seize personal assets such as money, motor vehicles, and real estate and use the proceeds for their budgets, even if the owner is never convicted of a crime. This sometimes leads to policies that target property instead of crime and are subject to abuse and corruption. Civil asset forfeiture may take place without proof of the origins or ownership of the asset and without a conviction of anyone for a criminal violation. Law enforcement retains the seized assets, or the proceeds from the sale of the assets, and uses the assets to fund further law enforcement efforts. Some argue that a dangerous incentive may be created for law enforcement to seize and keep assets at the expense of due process and individual liberties ( Drug Policy Alliance, 2009 ).

BOX 8.1 Presumed Guilty

Willie Jones, a second-generation nursery man on his family’s Nashville business, bundles up money from last year’s profits and heads off to buy flowers and shrubs in Houston. He makes this trip twice a year using cash, which the small growers prefer.

But this time, as he waits at the American Airlines gate in Nashville Metro Airport, he’s flanked by two police officers who escort him into a small office, search him and seize the $9,600 he’s carrying. A ticket agent had alerted the officers that a large black man had paid for his ticket in bills, unusual these days. Because of the cash, and the fact that he fit a “profile” of what drug dealers supposedly look like, they believed he was buying or selling drugs.

He’s free to go, he’s told. But they keep his money—his livelihood—and give him a receipt in its place.

No evidence of wrongdoing was ever produced. No charges were ever filed. As far as anyone knows, Willie Jones neither uses drugs nor buys or sells them. He is a gardening contractor who bought an airplane ticket. Who lost his hard-earned money to the cops. And can’t get it back.

Source: Copyright © Pittsburgh Post-Gazette, 2010. All Rights reserved. Reprinted with permission.

The Economics of Drug War/Peace

A frequent criticism of the war on drugs is that it simply has not worked. Testifying before a Senate committee, Henry L. Hinton of the General Accounting Office said,

“Despite long-standing efforts and expenditures of billions of dollars, illegal drugs still flood the United States. Although U.S. and host-nation counternarcotics efforts have resulted in the arrest of major drug traffickers and the seizure of large amounts of drugs, they have not materially reduced the availability of drugs in the United States.” ( U.S. General Accounting Office, 1998 )

More than 1.8 million people were arrested on drug law violations in 2007 within U.S. borders ( BOJS, 2010a ). In the second and third decades of the drug war, the number of people entering prison for drug offenses increased by more than 1,000 percent ( Justice Policy Institute, 2001 ), with a disproportionate number coming from minority populations. Despite these enforcement and interdiction efforts, drug-related emergency room admissions grew to 827,744 in the first six months of 2000 ( SAMHSA, 2001 ). Casual use of certain illicit drugs may have leveled off or decreased slightly, but a disturbing number of Americans still use illicit psychoactive substances ( Johnston, O’Malley, & Bachman, 2000 ).

Another criticism is that Americans cannot afford the war on drugs. From 1981 through 1988, the federal costs for this war were $16.5 billion ( Inciardi & McBride, 1989 ). In fiscal year 2002 alone, the enacted federal budget for the war on drugs was $18.8 billion, and the budget request for fiscal year 2003 was $19.2 billion ( ONDCP, 2002 ). One economist estimated that the cost of prohibiting illicit drugs was $48.7 billion in 2008. Roughly $33.1 billion in savings would accrue to state and local governments, while $15.6 billion would accrue to the federal government in reduced law enforcement costs. Government would gain another $34.3 billion through the taxation of marijuana, cocaine, and heroin ( Miron, 2010 ). A more optimistic article in  Business Week (2009)  estimated that such taxes could add more than $100 billion annually to governmental revenues. Further savings would accrue from not imprisoning drug offenders. At the rate of $17.1 million per day, their care cost state governments approximately $6.2 billion in 2007 ( BOJS, 2008 ).

The cost of abusing drugs is also very expensive. According to Office of the National Drug Control Policy, Americans spent $63.2 billion on illegal drugs in 1999 ( ONDCP, 2001 ). There was an additional economic cost to society of $109.9 billion: $77.6 billion in lost wages, $11.9 billion in health care costs, and another $20.4 billion in related costs such as depreciated property values and property damage, environmental damage, pain and suffering, and the like ( ONDCP, 2001 ). The economic cost of alcohol use was even higher at $165.5 billion, and tobacco use cost between $100 billion and $130 billion ( Hogan, 2000 ;  Leistikow, 2000 ). The total financial impact of substance abuse in the United States may be as high as $510 billion annually ( Evans, 1998 ).

The present policies on illicit drugs have amounted to a type of regressive tax: It has dramatically increased the profits of drug dealers and at the same time placed additional economic burdens on the residents of inner cities to provide more law enforcement and to ameliorate the effects of crime. In 2005, cocaine seizures reached an all-time high of 118,331 kilograms ( DEA, 2009 ). Politicians as well as police officers often herald such actions as proof not only of the severity of the drug problem but also of the success of the country’s interdiction efforts. However, it is questionable whether such raids prevent a single person from using cocaine. Likely no drug lords or street dealers are put out of business, and no additional addicts are driven to seek treatment. These events probably have no perceptible impact on the public’s attitudes toward drug use. People who want cocaine are still able to find it.

There is no reliable way of predicting how much drug use would increase or decrease under a policy of legalization or decriminalization. In Great Britain, the number of addicts seeking treatment increased after passage of the Dangerous Drugs Act (which decriminalized the use of heroin and other illicit drugs), but it is not known to what extent drug use increased or decreased. There is some evidence that marijuana use decreased immediately after the Dutch government decriminalized its use in 1976, however ( Dennis, 1990 ). Both Great Britain and the Netherlands are far different from the United States in culture and economic demographics. One cannot assume that Washington, DC, would react to legalization in the same manner as London or Amsterdam. The Netherlands has a homicide rate only one-eighth that of the United States. Important aspects of its overall drug policy are also very different.

After reviewing hundreds of drug war studies by criminologists, psychologists, sociologists, and economists,  Benson and Rasmussen (1994)  concluded that not only is the United States not winning the drug war, but it is essentially an unwinnable war. Furthermore, by engaging in this war, the nation’s resources have been stretched to the point where the entire criminal justice system is in a state of crisis. Their conclusion is that the United States will have to learn to coexist with the illicit drug trade and find a rational means of allocating its criminal justice resources. For example, local courts could be assigned a quota of treatment slots for their use. Judges (and voters) would no longer be forced to face decisions that result in a rapist receiving an early release from prison so that a nonviolent crack addict could be incarcerated.

A similar conclusion was reached by the Latin American Commission on Drugs and Democracy. In a report presented in Rio de Janeiro, it concluded that

“The war on drugs has failed. And it’s high time to replace an ineffective strategy with more humane and efficient drug policies . . . The revision of U.S.-inspired drug policies is urgent in light of the rising levels of violence and corruption associated with narcotics. The alarming power of the drug cartels is leading to a criminalization of politics and a politicization of crime. And the corruption of the judicial and political system is undermining the foundations of democracy in several Latin American countries.” ( Wall Street Journal, 2009 )

Legalization

We must remember that in the absence of any convincing empirical data regarding the effectiveness of alternative policies toward illicit drugs, the U.S. political system encourages the use of symbolic values (e.g., increased law enforcement) that become just as important, if not more important, than any tangible outcomes. Thus, the debate over the legalization of illicit drugs has strong moral overtones.

Have Drug Laws Created Problems Worse than the Drugs Themselves?

Is it reasonable to say that present drug policies are responsible for increased corruption, violence, street crime, and disrespect for the law? There is obviously much truth in these assertions. One could easily argue that present policies have made the sale of illicit drugs a highly profitable enterprise—so profitable that “turf wars” among cartels and neighborhood dealers alike have led to remarkable increases in the homicide rate. One only has to read the headlines in any Washington, DC, newspaper to learn that the great majority of homicides in the nation’s capital (also the nation’s murder capital) are drug related. On the other hand, the evidence suggests that among the majority of street drug users who are involved in crime, their criminal careers were well established prior to the onset of their drug use ( Inciardi & McBride, 1989 ). As mentioned in previous chapters, their drug involvement may be due primarily to their involvement in a criminal subculture.

Perhaps more important is that the present laws, coupled with the propaganda fed to children for two generations about the consequences of drugs such as marijuana, have resulted in disbelief and widespread criminal violations. There is a direct parallel between this situation and the consequences of Prohibition, during which the law made criminals of millions of otherwise honest citizens.

Has Law Enforcement Failed in Reducing the Supply and the Demand for Drugs?

A closely related argument often made by advocates of legalization is that the $30 billion a year currently spent for law enforcement could be better used for the treatment and prevention of drug abuse. The use of drugs among U.S. secondary school students remains high. In 2007, 19.5 percent of state and 56.4 percent of federal inmates were incarcerated for drug offenses (BJS, 2008). It is obvious that law enforcement has failed as a solution to the problem of illicit drugs.

Can One Stop the Use of Drugs That a Significant Segment of the Population Is Committed to Using?

It is simply impossible to arrest, prosecute, and punish such large numbers of people, especially in a liberal democracy in which the government must not unduly interfere with personal behavior. Attempting to enforce draconian measures against drug users not only places a great fiscal burden on the nation, but it also poses an imminent threat to the civil liberties of its citizens.

Is Illicit Drug Use as Great a Threat to Society as the Legally Sanctioned Use of Alcohol and Tobacco?

The Surgeon General of the United States has estimated that cigarette smoking (the leading preventable cause of death in the United States) alone kills approximately 438,000 people a year, almost one in five deaths ( CDCP, 2009a ). Cigarette smoking kills more people each year than all other drugs combined and is virtually always addicting. Sales of tobacco are not just legal—they are actually subsidized by government programs providing price supports for tobacco growers! By comparison, from 2001–2005, there were approximately 79,000 deaths annually attributable to excessive alcohol use ( CDCP, 2009b ).These figures are almost certainly conservative estimates of alcohol-related deaths. Compare these numbers with the estimated mortality rate of 15,973 deaths from illicit drug use, and one must wonder why cocaine, marijuana, and heroin are regarded as being so dangerous ( ONDCP, 2001 ). To focus on a strong drugs/crime connection, one must remember that more than half of all people convicted of violent crimes were under the influence of alcohol at the time the crime was committed ( Bradley, 1987 ). Alcohol abuse is also implicated in a major portion of domestic violence incidents ( Lehmann & Drupp, 1983–84 ).

What Are the Possible Benefits of Legalization?

Among the expected benefits of legalization are cheaper drug prices, a decrease in drug-related crime, less corruption of governmental officials, and a destruction of the power base of drug lords and criminal syndicates. In addition, the U.S. legal system would be free to use more of its resources to provide treatment to addicts, to prosecute and punish real criminals, and to eliminate the threat to civil liberties contained in current policies. Finally, government-sanctioned sales outlets could provide quality control to see that drug users are not harmed by tainted drugs and could collect badly needed tax revenues. We mentioned earlier that Oakland voters approved the taxation of medical marijuana ( CNN, 2009 ). In recent years twenty states have approved legislation taxing illegal marijuana, but most of these laws are not intended as revenue raising measures. For example, in Minnesota, failure to comply with the state’s drug tax law may result in a fine of up to $14,000 and seven years in jail ( NORML, 2009a ).

Would Legalization Result in Increased Drug Use, Loss of Productivity, and Higher Health Care Costs?

Some people argue that legalization could imply approval and lead to increased use. (If arguing that drug legalization would persuade people that drugs are safe, then the obvious implication is that the country needs to reconsider its policies on alcohol and tobacco!) Even if drug use were to increase with legalization, however, the economic benefits of “drug peace” would in all likelihood pay for the additional costs of increased usage, both socially and economically. As the earlier analysis indicated, the break-even point would be close to a 100 percent increase, and not even the most severe critics of legalization are predicting such dire consequences. Most people would not want to risk the harm caused by addiction, however.

Will Drug Users Seek Greater Quantities and Higher Potencies of Drugs on the Black Market?

If the government legalized drugs but restricted the amount and potency of drugs that a person could legally purchase, it is likely that some people would seek greater quantities and higher potencies in an underground market. In order to work, legalization must make drugs available at all levels of quantity and potency. Otherwise, an underground market in drugs will continue.

Will Legalizing “Soft” Drugs Such as Marijuana Lead Its Users to More Harmful and Addictive Drugs?

If the government wants to restrict so-called gateway drugs (drugs that young people use that appear to be precursors of later drug use), then it should place restrictions on alcohol and tobacco, especially tobacco. Moreover, keeping marijuana illegal forces buyers into an underground market where they are likely to be offered other illegal drugs. Finally, some 60 million Americans have tried marijuana, and the number of cocaine addicts is estimated at 1 million. Thus, most marijuana smokers did not graduate to stronger drugs. The gateway effect is apparently not very strong. Some believe that it does not exist.

Proposals for the legalization or decriminalization of drugs are incomplete and imperfect. There are still too many unanswered questions for the country to change course abruptly on these policy issues. Before people can seriously consider radical alternatives to the war on drugs, they need to answer the following questions asked by Paul Stares (1996):

· What is the range of regulatory permutations for each drug?

· What would happen to drug consumption under more permissive policies?

· What would happen to crime under decriminalization? Legalization?

· Would a black market for drugs emerge under legalization?

· Would regulations restricting the purchase of drugs be as difficult to enforce as today’s alcohol and tobacco restrictions?

· How would a decision to legalize drugs affect other countries? (pp. 18–20)

Merely asking these questions will anger many people, but the United States must begin to fashion a comprehensive, consistent, and enforceable policy regarding the use of drugs. These questions, and many others, must be answered before the political system is ready to consider an abrupt change in policy. Without serious investigation and a minimum degree of consensus on a number of these issues, the nation is not likely to deviate much from its present course.

Medical Marijuana

Beginning in April, 2009, patients in Michigan began applying to register with the Michigan Medical Marijuana Program. Patients in the program are permitted under state law to possess and grow cannabis for medical purposes. Michigan became the thirteenth state to allow the physician-supervised use of marijuana under state law ( NORML, 2009b ). Canada also allows some patients to possess cannabis and to grow a limited number of plants ( BBC News, 2001 ). This issue will not be so quickly resolved in the United States, since all parties seem to be zealously committed to maintaining their respective positions ( McNeece et al., 2001 ).

Like so many other illicit substances, marijuana has been used as a popular medication all over the world for hundreds of years. No serious concerns about its use were expressed until the late nineteenth century in England, which led to an extensive investigation and publication of Indian Hemp Commission Report in 1898. The commission concluded that the drug had many practical uses in medicine and that many of the stories of its dangers could not be documented ( McNeece et al., 2001 ). As noted earlier (see  Chapter 1 ), there was little public interest in controlling marijuana until its use became associated the “dangerous classes” of people, such as African American jazz musicians and Mexican migrant workers. In response, the Marijuana Tax Act was passed in 1937 with no debate and with no input from medical practitioners ( Becker, 1967 ).

After two years of extensive investigation, the Schafer Commission, appointed by President Nixon, issued a report in 1972 called Marijuana: Signal of Misunderstanding. The report found very little in the way of toxic effects, leading the commission to conclude that decriminalization of marijuana might be the most appropriate policy. The report incensed the president, however, who stated that he would never accept legalization of marijuana ( McNeece et al., 2001 ). Another research monograph entitled Marijuana and Health was produced by the Department of Health and Human Services in 1982 during the first Reagan administration. This time, the experts noted serious health problems associated with marijuana use. Given the conflicting observations by different panels of experts, the debate over the effects of smoking marijuana has continued unabated.

Even so, large numbers of medical patients, especially cancer patients, have demanded legal access to marijuana. Many claim that it is effective in alleviating the side effects of chemotherapy and radiation and that it is useful for treating both glaucoma and AIDS symptoms ( Stolberg, 1999 ). Laws that allow its medical use do not legalize marijuana or alter criminal penalties regarding the possession or cultivation of marijuana for recreational use, nor do they establish a legal supply for patients to obtain the drug. They merely provide a narrow exemption from prosecution for defined patients who use marijuana with their doctors’ recommendation. In addition, the intent was to allow physicians to prescribe marijuana to patients without the fear of arrest. The federal government responded by threatening physicians with revocation of their federal prescription-writing privileges. The matter is still under review by the courts.

Representative Barney Frank (D-Mass.) reintroduced legislation in Congress in 2001 to provide for the medical use of marijuana. House Bill 912, the Medical Use of Marijuana Act, would have moved marijuana from Schedule I to Schedule II under federal law, thereby making it legal for physicians to prescribe. The rescheduling would remove cannabis from the list of drugs alleged to have no valid medical use, such as heroin and LSD, and put it in the same category as Marinol, morphine, and cocaine. (Many marijuana users believe that the pill form, Marinol, is not as effective as smoking marijuana.) If passed, House Bill 912 would not have required any state to change its current laws. Rather, it would have allowed states to determine for themselves whether marijuana should be legal for medicinal use. The bill failed, and unfortunately, the issue will probably not be resolved on the basis of scientific research, since medical marijuana is as much a political cause as a scientific issue. The expediencies of politics are more likely to triumph over reason.

Drugs, Alcohol, and Crime

There is certainly a relationship among alcohol, drugs, and crime. The exact nature of that relationship is quite complex, however, and scholars are still putting the pieces together.  Rasmussen and Benson (1990)  argue that the great majority of persons who are arrested for drug offenses are not participating in other types of more violent criminal activity. On the other hand, research shows that the great majority of persons arrested in urban areas for all crimes test positive for illicit drug use ( National Institute of Justice, 1990 ). The effects of substance abuse on crime depend on (1) what drug is being used, (2) who is using the drug, (3) the relationship of the user to subcultures tolerant of other forms of social deviance, (4) law enforcement policies regarding drug use, and, perhaps most important of all, (5) who is conducting the research.

People who use drugs (except alcohol, tobacco, and certain legal prescription drugs) are committing a criminal act. There are some very persuasive arguments that because of society’s unreasonable definitions of drug use per se as a criminal act, society forces drug users to become criminals. Labeling theorists such as  Lemert (1966)  argue that the secondary deviance that attaches to a person who is arrested or incarcerated for drug offenses can be far more destructive than the consequences of the drug use itself. For the most part, however, society seems to be more concerned with whether other nondrug crime, particularly street crime, is a direct result of drug-taking behavior. Labeling, stigmatization, and secondary deviance are rather remote issues for citizens facing a crime wave.

Three hypotheses continue to dominate the drugs/crime controversy. The first maintains that the “addict of lower socio-economic class is a criminal primarily because illicit narcotics are costly and because he can secure his daily requirements only by committing crimes that will pay for them” ( Tappan, 1960 ). According to this hypothesis, criminality is a more or less direct consequence of physical dependence and tolerance, which requires ever-increasing doses of a drug that is economically unavailable to the addict with limited financial means.

The second hypothesis maintains that the “principal explanation for the association between drug abuse and crime . . . is likely to be found in the subcultural attachment” of the drug abuser to criminal associations, identifications, and activities of other persons who are addicted ( Goldman, 1981 ). This hypothesis is more pertinent to the hard drugs such as heroin—a drug that is closely associated with a criminal subculture. It is less useful when applied to the soft drugs such as marijuana, as most middle-class college students could eagerly testify. Even cocaine seems to be a favorite drug of some business executives and other middle-class citizens.

A third theory holds that drug dependence is functional, as opposed to casual or recreational ( Alexander, 1990 ). The addict’s behavior is an attempt to deal with his or her failure to achieve social acceptance, competence, self-confidence, and personal autonomy. This adaptive model sees drug dependence as a “strategy to remove the individual (a retreat) from competitive situations in which defeat is almost certain” ( Alexander, 1990 , p. 45). The addict’s behavior is seen as self-directed and purposeful, although not necessarily on a conscious level ( Abadinsky, 2001 ).

The category of crime known as domestic violence (spousal abuse, child abuse, etc.) has been linked to alcohol and drug abuse so frequently and so consistently that one might also hypothesize a direct, causal relationship between drug use and certain crimes of violence ( Langley & Levy, 1977 ). Alcohol, especially, is said to have a disinhibiting effect that unleashes emotions such as rage or at least lessens the ability to control rage ( Shainess, 1977 ). In a study of 234 abusers of women appearing before the court in Indianapolis, 60 percent had been under the influence of alcohol and 21.8 percent had been under the influence of other drugs when they physically assaulted their spouses or partners. The men who were using alcohol or drugs generally displayed greater violence toward the women ( Roberts, 1987 ).

Nonetheless, with few exceptions, there is no evidence of a clear cause-and-effect relationship between alcohol or drug use and violent behavior. Drugs such as PCP and amphetamines are known to affect the brain in some way that triggers violent behavior ( Roberts, 1988 ). However, central nervous system depressants and marijuana generally alter behavior in the opposite direction ( White, 1991 ). There are reasons to suspect that much of the domestic violence that occurs under the influence of alcohol or drugs is preplanned. According to the disavowal theory, the abuser simply gets drunk or gets high so that he will have an excuse for beating his wife or children. By doing so, both his family and society may treat him less severely ( Wright, 1985 ).

There is much evidence that most of the current problems of the criminal justice system can be attributed, either directly or indirectly, to drugs: jail and prison overcrowding, court backlogs, increased crime, inmate violence, and the increased costs of incarceration. Strains on the system caused by the increased use of drugs have resulted in frequent crisis management and a “continuing search for more effective ways for the system to absorb the increase in drug arrests and to reduce the cycle of drug use and arrest for these defendants” ( Belenko, 1990 , p. 27).

The data discussed on the following pages show an undeniable relationship among alcohol, drugs, and crime. One task will be to understand whether the socioeconomic class approach, the subcultural attachment approach, or some other hypothesis best explains the nature of that relationship. First, drug law violations (manufacture, use, and sales) as crimes will be examined. Next, there will be a discussion about substance abuse and criminal histories of people arrested or incarcerated for nondrug crime. Third will be a review of the research on substance abuse and domestic violence. Finally, current trends in the drugs/crime relationship will be examined, and current policies regarding drugs and crime will be reviewed.

Alcohol and Drug Law Violations

It is no secret that crime statistics are regarded by the experts as seriously flawed. Despite such impressive titles as Uniform Crime Reports that fill the basements of university libraries, there is actually very little uniformity in reporting practices. Crime statistics are based on reports taken by thousands of local police officers and county sheriffs. Crime statistics in a community may change dramatically overnight with a change in reporting procedures. Police commissioners arguing for larger budgets have been known to create their own crime waves simply by altering departmental rules for reporting crime.

Anyone doing research on juvenile delinquency certainly has been frustrated by the tremendous variability in state and local reporting procedures. Only about two-thirds of the states regularly report juvenile crime data to a central national registry, and many local jurisdictions are not required to report to a central state agency. There is no way to determine how many juveniles were arrested in Texas or Illinois (or several other states), for example, for drug law violations, except by reviewing records of local police. (Imagine examining the records of 254 county sheriffs and hundreds of city police departments in a state the size of Texas!)

Crime data, although seriously flawed, can be of some help in understanding the drugs/crime relationship, however. Some categories of drug-related offenses, such as adult arrests for drug law violations, are reported with much greater regularity and consistency because of stricter federal standards for reporting. Also, one can assume that the direction of error in crime data is toward underreporting. On a nationwide basis, one also can assume that the degree of underreporting is fairly consistent from one year to the next. Therefore, if dramatic changes occur over a period of years, one may still be able to identify specific trends.

TABLE 8.1 Sentenced State Prisoners for Drug Offenses by Race, 2000 and 2006

	2000	2006	% Change
White	72,000	85,800	+19.2
Black	115,700	86,100	−25.6
Hispanic	54,100	64,900	+20.0

Source: Bureau of Justice Statistics, Prisoners in 2008. NCJ 228417,  http://bjs.ojp.usdoj.gov/content/pub/pdf/p08.pdf.

The increase in adult incarcerations for drug violations in recent years is clear (see  Table 8.1 ). Does this mean that there was a comparable increase in illegal drug manufacture, sale, or possession during that period? It’s impossible to say. In some communities, there may actually be much smaller increases or possibly even a decrease. Other data indicate that the overall crime rate peaked and began to decrease during the 1990s ( Bureau of Justice Statistics, 1996 , p. 10). Despite this trend, vigorous enforcement of drug laws could still produce an increasing number of arrests and commitments in this category each year.

TABLE 8.2 Estimated Number of Sentenced Prisoners under State or Federal Jurisdiction, by Race and Hispanic Origin, 2000–2008

Year	Total	White	Black	Hispanic
2000	1,321,200	471,000	610,300	216,900
2001	1,344,500	485,400	622,200	209,900
2002	1,380,300	472,200	622,700	250,000
2003	1,409,300	493,400	621,300	268,100
2004	1,433,800	491,800	583,400	275,600
2005	1,461,100	505,500	577,100	294,900
2006	1,502,200	527,100	562,800	308,000
2007	1,532,800	521,900	586,200	318,800
2008	1,540,100	528,200	591,900	313,100

Source: Bureau of Justice Statistics, Prisoners in 2008. NCJ 228417,  http://bjs.ojp.usdoj.gov/content/pub/pdf/p08.pdf .

Juvenile arrest data also indicate an increase in juvenile drug arrests of 125 percent between 1988 and 1997 ( OJJDP, October 2000b ), and a disproportionate number of juvenile drug offenders who were waived to adult criminal court were African American ( OJJDP, August 2000a ). Our best estimates indicate that 195,700 juveniles were arrested for drug law violations in 2007 ( BOJS, 2010a ).

In order to more fully understand the trends in drug law violations and imprisonment, one must study the data by gender and ethnicity. While the number of female drug offenders imprisoned in state prisons grew by 35 percent between 1990 and 1999, the comparable rate for males was only 19 percent ( BOJS, 2001 ). While women prisoners are about 7 percent of the total prison population, they account for 10 percent of incarcerated drug offenders ( BOJS, 2008 ). Although blacks are still being incarcerated at a rate 650 percent greater than whites, the number of incarcerated black drug offenders fell by more than a quarter in recent years  (see Table 8.1 ). The total number of black prisoners has fallen slightly, but they are still 38.4 percent of the total prison population, and Hispanics account for 20.3 percent (see  Table 8.2 ). The racial composition of the U.S. prison population is even more disturbing when we realize that almost 10 percent of African American males between the ages of 20 and 29 are in prison, and they are there primarily for drug offenses. Equally disturbing is the fact that 60.9 percent of the growth in the number of federal inmates between 1990 and 1999 was due to drug offenses ( BOJS, 2001 ).

With 2,424,279 persons incarcerated in U.S. jails, juvenile detention facilities, state and federal prisons, and other detention facilities at year end 2008 ( BOJS, 2009 ), largely as a result of drug law enforcement, we must wonder how much longer we can afford to fight the war on drugs.

Drug Use by Criminals

In 1986, almost half of all prisoners in state institutions either had been convicted of a drug crime or had been a daily user of an illegal drug in the month preceding the offense for which they were incarcerated ( BOJS, 1997 ). Although comparable data are not available for subsequent years, there is convincing evidence that even more prisoners are drug involved. There were 1,645,500 adults and 195,700 juveniles arrested for drug law violations in 2007 ( BOJS, 2010a ).

In the 1986 study, 28 percent of prison inmates reported a past drug dependency. The drugs most frequently mentioned were heroin (14 percent), cocaine (10 percent), and marijuana or hashish (9 percent). At the time of the offense,17 percent were under the influence of drugs only, 19 percent were under the influence of alcohol only, and 18 percent were under the influence of both drugs and alcohol. More than half said they had taken illegal drugs during the month before committing the crime, and 43 percent said that they had used drugs on a daily basis just prior to committing the crime ( BOJS, 1988b ).

The latest arrestee drug abuse monitoring (ADAM) statistics, which are for 2003, indicate that 70.3 percent of male arrestees in 39 major metropolitan areas across the United States tested positive for an illicit drug and 93.4 percent tested positive for either alcohol or an illicit drug. Marijuana remains the predominant drug among adult and juvenile male arrestees (44.1%), although cocaine is a close second (NORC, 2003).

There is ample evidence that offenders are more likely than nonoffenders to use alcohol and illegal drugs, but does that mean that the drug use caused the crime?  Huizinga and associates (1989)  examined the temporal order of drug and alcohol use and other delinquent behavior and concluded that other delinquency generally precedes the use of alcohol or drugs. Therefore, alcohol and drug use cannot be the cause of other delinquent behavior. However, the same study concludes that there may be causal relationships within the arena of drug law violations:

1. The onset of alcohol use precedes the onset of either marijuana or polydrug use in 95 percent of all ascertainable cases; among those who never use alcohol, no more than 3 percent initiate marijuana use and no more than1 percent initiate polydrug use.

2. Marijuana use precedes the onset of polydrug use in 95 percent of ascertainable cases (p. 448).

It should be stressed that this (and earlier) studies of the drugs/juvenile delinquency relationship were concerned more with alcohol and the soft drugs than with hard drugs such as heroin. Remember the earlier caveat regarding the nature of the drug having an impact on its connection with criminal behavior. Heroin and cocaine both produce a much more powerful physical craving in the addicted person than drugs such as marijuana, and these drugs are much more expensive than alcohol. The alcoholic and the regular marijuana user can ordinarily maintain his or her life-style through regular employment.

Research in Maryland (Baltimore), California, and New York (Harlem) indicates that criminal activity increases with higher levels of heroin use.  Ball, Shaffer, and Nurco (1983)  found that over a nine-year period, the crime rate of 354 heroin addicts dropped with less narcotics use and rose 400 to 600 percent with increased use. An earlier paper on the Baltimore study estimated that male opiate addicts commit crimes on an average of 178 days per year ( Ball, Rosen, Flueck, & Nurco, 1982 ). A study of Harlem heroin users found that daily users committed about five times as many robberies and burglaries as irregular users, an average of 209 per year ( Johnson et al., 1985 ). Obviously, users are apprehended for only a tiny fraction of these crimes.

Other research on the relationship between drugs and crime indicates that the relationship is more complicated than previously thought. For example, groups of individuals with low levels of antisocial personality and self-derogation are most directly affected by the use of drugs during adolescence. They are likely to experience loss of inhibitions and to engage in acts of violence later in life ( Kaplan & Damphousse, 1995 ).

Drug Use by Crime Victims

There is evidence that drinking alcohol or using drugs increases the likelihood of being a crime victim. According to the lifestyle/exposure theory, routines or lifestyles involving alcohol or drug use may facilitate the spatial and temporal union of victims and criminals ( Hindelang, Gottfredson, & Garofalo, 1978 ). Ask any police officer about hanging around bars drinking or going into inner-city crack houses to buy and/or use drugs. These are both regarded as very high-risk activities.

A study of over 6,000 cases in England strongly supports the contention that drinking at night away from home greatly increases the prospects of the drinker’s suffering a personal attack or injury. For young male respondents, the probability of enduring a serious personal injury as a result of such a lifestyle was even greater ( Lasley, 1989 ). People who use drugs or alcohol away from home are frequently in unfamiliar environments, surrounded by others who are involved in all types of criminal activities. Drug users have a diminished capacity for flight or self-protection. Women who attend raves and use club drugs such as “X” or “Special K” may be particularly vulnerable to rape ( NIDA, 2008 ).

Domestic Violence

There has traditionally been a high degree of family violence in the United States, as well as an unwillingness to look too closely at the serious incidents of physical abuse that occur in many homes. Shame, guilt, fear of reprisal, and lack of appropriate community responses have prevented many victims from reporting these crimes. Today, public attitudes allow more and more victims of abuse to take a stand against their abusers, as prison convictions have increased and the number of “safe houses” has grown. Even so, reports of alcohol- and drug-related family violence remain high, with an estimated 826,000 child victims of family violence in 1999 ( National Clearinghouse, 2001 ).

Public opinion has long held that the wife beater or child abuser is a “lower class, beer-drinking, undershirt-wearing Stanley Kowalski brute” ( Langley & Levy, 1977 ). Family violence is not confined to any social, geographic, economic, or racial/ethnic group, but it is strongly connected to the use of alcohol and drugs. More than three decades ago, Dr. Henry Kempe estimated that alcohol plays a role in about a third of all cases of child abuse ( Kempe & Helfer, 1972 ). A study conducted at an Arkansas alcoholism treatment center indicated that more than half of the parents being treated were also child abusers ( Spieker, 1978 ). Another study in New York found that the husband’s alcohol or drug abuse was an underlying factor in over 80 percent of wife-beating cases ( Roy, 1977 ). More recently, research in Indianapolis showed that more serious physical abuse is likely to be committed by men with alcohol or drug problems ( Roberts, 1988 ). According to the National Institute on Alcohol Abuse and Alcoholism ( NIAAA, 2000 ), as many as 60 percent of male alcoholics were violent toward a woman partner in the last year, and alcohol is implicated in 30 percent of all child abuse cases.  Liebschutz, Mulvey, and Samet (1997)  found that 42 percent of a sample of women who were seeking treatment for substance use problems had been physically or sexually abused at some point in their lives. Another study of inpatients being treated for alcoholism found that 49 percent of the women and 12 percent of the men reported that they had been sexually abused ( Windle, Windle, Scheidt, & Miller, 1995 ).

According to  Cohen (1981) , violence among alcohol and drug users may occur because human aggression may be increased through drug use, and this propensity is dose related. Some of the possible explanations for this phenomenon are as follow:

1. The drug might diminish ego controls over comportment, releasing submerged anger that can come forth as directed or diffuse outbursts.

2. It may impair judgment and psychomotor performance, making the individual dangerous to self and to others.

3. It might induce restlessness, irritability, and impulsivity, causing hostile combativeness.

4. The drug could produce a paranoid thought disorder with a misreading of reality. False ideas of suspicion or persecution may bring forth assaultive acts against the imagined tormentors.

5. The craving to obtain and use the drug can result in a variety of criminal behaviors, some of them assaultive.

6. An intoxicated or delirium state may result in combativeness and outbursts of poorly directed hyperactivity and violence.

7. Drug-induced feelings of bravado or omnipotence may obliterate one’s ordinary sense of caution and prudence causing harm to one’s self or others.

8. An amnesic or fugue state may occur during which unpredictable and irrational assaults may take place (pp. 358–359).

In the case of certain drugs, such as ice, there is an almost certain direct link between drug use and violent or aggressive behavior. With alcohol, however, this relationship is somewhat more indirect. As noted earlier, the most widely accepted viewpoint is that alcohol abuse is a disavowal technique used by abusive husbands to excuse their behavior.

Drug/Crime Trends in the 21st Century

In addition to the dramatic increase in illicit drug use that has been observed during the past decade, some other disturbing trends are developing that merit special attention.

Drug Trafficking

The massive problem of illicit drug use in the United States is not the result of independent manufacturers, growers, and drug dealers. It takes a great deal of organized effort to bring cocaine from Peru, heroin from Pakistan, and cannabis from Mexico into this country in a sufficient volume to satisfy current demand. Law enforcement officials’ intelligence on drug distribution networks indicates that a number of well-organized, large, highly competitive regional organizations as well as hundreds of small, independent dealers are involved in the illicit drug trade. Traditional organized crime syndicates, small ethnic groups, street gangs, and motorcycle gangs are all involved in the importation, manufacture, distribution, and sale of illegal drugs ( ONDCP, 2001 ).

The growth of nontraditional organized crime is one of the most recent phenomena in illicit drug trafficking. Outlaw motorcycle gangs have been deeply involved in Oklahoma(Outlaws), Texas (Bandidos, Scorpions, Banshees, Ghostriders, Freewheelers, and Conquistadors), and several other states ( ONDCP, 2001 ). A shootout in Nevada between the Hell’s Angels and rival motorcycle gangs (Mongols, Bandidos, Outlaws, Pagans, Sons, and Vagos) may have been mostly a dispute over drug markets ( Wilborn, 2002 ). Los Angeles gangs, primarily the Crips and the Bloods, have developed far-reaching illicit drug networks that operate in Oregon, Washington, Missouri, Maryland, Texas, Colorado, and New York. In some communities, such as Seattle, Tacoma, and Denver, they have dominated the trade in crack cocaine.

Most of the recent attention to drug trafficking has been focused on the Medellin cartel in Columbia ( Cardona, 2010 ) and the drug-related violence along the Mexican border. Since Mexican President Felipe Calderon’s election in September 2009, newspapers estimated the number of killings at more than 13,600 persons. The violence has reached such high levels that Mexican public officials almost never appear in public without hundreds, sometimes thousands, of federal troops for protection. Many law enforcement personnel, both Mexican and American, have been killed in drug-related shoot-outs in cities like Ciudad Juarez ( Hidalgo, 2010 ).

Drugs, Crime, and Prison

As indicated earlier in this chapter, the U.S.correctional population is approaching 2.5 million, due largely to an increase in admissions for drug offenses (see  Table 8.2 ). Between 1988 and 1997, drug offenders accounted for 61 percent of the total growth in the federal prison population ( BOJS, 2001 ). One reason for this dramatic growth in drug-related prison admissions is parole failure and revocation. Increased emphasis on drug testing and the intensive surveillance of parolees has resulted in sharp increases in the number of drug offenders who are returned to prison. Approximately one of three prison admissions is someone who has failed to complete his or her parole satisfactorily, and the primary reason for parole failure is the use or possession of drugs ( Criminal Justice Estimating Conference, 1989 ). In several states, prison admissions for parole violations have exceeded prison admissions for new court sentences ( BOJS, 2001 ).

The already high incarceration rate for minorities has exploded with the “get-tough” policies of the war on drugs. Drug enforcement has somewhat narrowly focused on crack, a favorite illicit drug among the poor, who are also disproportionately African American and Hispanic American. In Virginia, new drug commitments of whites fell from 62 percent of total drug commitments in 1983 to 34 percent in 1989, with minority commitments rising from 38 percent to 66 percent. A majority of all drug offenders in state and federal prisons are African American ( BOJS, 2009 ).

There seems to be reasonable evidence that institutional racism has influenced drug law enforcement. Mandatory minimum sentences force judges to incarcerate many drug violators who would not otherwise be sent to prison, and these sentences appear to apply more often to blacks than whites. For example, a conviction in federal court for possessing 5 grams of crack cocaine results in a five-year mandatory sentence, but 500 grams of cocaine powder is required to invoke to same sentence. In 1995, the U.S.Congress rejected the U.S. Sentencing Commission’s recommendation that sentences for crack (more frequently used by black arrestees) and cocaine powder be equalized. However, the Supreme Court ruled in Kimbrough v. United States (2007) that the Guidelines for cocaine are advisory only, and that a judge may consider the disparity in the guidelines for sentencing crack and powder cocaine offenders.

Treating Substance-Abusing Offenders

Law enforcement and corrections administrators have responded to the growing number of alcohol- and drug-involved arrests by increasing the enrollment of offenders in diversion, jail-based, probation, and prison drug treatment programs. In 1979, an estimated 4.4 percent of inmates in state correctional systems were in treatment (NIDA, 1981). By 1987, this figure had grown to 11.1 percent ( Chaiken, 1989 ). By 1995, there were 39 special state correctional facilities designed primarily for alcohol or drug treatment ( BOJS, 1997 ). There were few such special federal facilities at that time. However, by 2008, there were 17,523 federal inmates in residential drug treatment programs, 14,208 in nonresidential programs, 23,230 in drug education programs, and 15,456 in community transitional programs (BOP, 2009).

The most common types of treatment programs in jails and state prisons are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other Twelve-Step approaches modeled closely after AA and NA. States estimate that 70 to 85 percent of inmates need substance abuse treatment, but only 13 percent receive any ( Blanchard, 1999 ). It is no wonder that recidivism rates for incarcerated drug offenders are high.

Professionals outside the correctional system might assume that treatment routinely would be provided to chemically dependent inmates. After all, it makes little sense to incarcerate cocaine-abusing offenders for a period of years and then send them back to the community without treatment! However, one must consider the barriers to providing treatment within a prison, such as constraints on resources, changes in priorities for specific types of programs, staff resistance, and inmate resistance ( Chaiken, 1989 ). Prisons and jails are, first and foremost, institutions designed for control and punishment of criminal offenders.

The literature on treatment of chemically dependent offenders presents a somewhat confusing picture. Some evaluations of treatment programs sometimes indicate little or no effect ( Vito, 1978 ); whereas others show that treatment decreased subsequent criminal activity and normalized the lifestyles of offenders ( Field, 1989 ). One Bureau of Prisons study, conducted in 1998, indicated that federal inmates who were provided drug treatment had a 3.3 percent recidivism rate in the first six months after release, compared to 12.1 percent for those without treatment ( ONDCP, 2001 ). Very little of the research followed offenders for a sufficiently long post-treatment phase to generate much confidence in findings of success.

However, states and communities are once more increasing the availability of treatment for incarcerated offenders ( Marks, 1999 ), and since the Violent Crime Control and Law Enforcement Act of 1994, all federal inmates have an opportunity for treatment prior to release ( Blanchard, 1999 ). Nevertheless, in 1998, only 11 percent of state inmates received drug treatment ( ONDCP, 2001 ). There is also some evidence of success in diversion efforts in California, where Proposition 36 has mandated treatment rather than incarceration for first- and second-time offenders ( Drug Policy Alliance, 2002 ).

Historically, methadone maintenance programs have been a major treatment modality for drug-involved criminal offenders. Studies of such programs in New York City since the 1950s indicate that methadone maintenance may be the most cost-effective outpatient treatment for the majority of opiate addicts under probation or parole supervision ( Joseph, 1988 ). Unfortunately, many patients maintained on methadone also have serious alcohol and/or cocaine addictions. In such cases, a choice of other treatment alternatives should also be available.

Therapeutic communities (TCs) have a long history of providing treatment to criminally involved drug addicts. Until 1975, drug abusers were sent to TCs under civil commitment procedures by both federal and state courts. Since 1975, the civil commitment procedures have been gradually replaced with legal referrals, which are equally coercive. Some TCs serve criminal justice clients almost exclusively. Clients in a therapeutic community are isolated from the outside world. Their philosophy is that there is no cure, just control. Addicts are kept away from the neighborhood, friends, and situations that have been a part of their addiction. The aim of TCs sounds surprisingly similar to the early moralistic treatments: to restructure an immature, addiction-prone individual into a strong, self-reliant person who no longer needs a drug (Springer, NcNeece, & Arnold, in press). Reviews of the research indicate that TCs are effective with legally coerced clients ( ONDCP, 1996 ;  Wexler, 1994 ).

There are obvious explanations for many of the higher success rates claimed by treatment programs that work with legally coerced clients. First, residential programs such as TCs may require clients to be in residence for a year or more, and these clients are under constant scrutiny by staff and other residents. The risk of detection under such circumstances is quite high, and more successful outcomes are related to longer periods of treatment ( Gerstein & Harwood, 1990 ). Second, clients in both residential and nonresidential programs may be on long-term parole or probation. Such clients may be routinely monitored either by treatment staff or by probation/parole officers for possible drug use, including unannounced urine analysis. Finally, the threat of legal coercion (being returned to jail or prison) may simply have a deterrent effect.

Whatever one may think of the appropriateness of the coerced-treatment approach, since passage of the Anti-Drug Abuse Act of 1988, the majority of illicit drug users in treatment in most communities have been treated through the justice system. Additional funding for treating criminal offenders came from the Edward J. Byrne Memorial Fund, which replaced the Anti-Drug Abuse Act. It was subsequently reauthorized under the American Recovery and Reinvestment Act of 2009 (Public Law 111-5). Without these approaches, there would have been little treatment of any kind for criminal offenders available within the community ( McNeece, 1991 ).

Drug Courts

A promising alternative to combat the growing substance abuse problem in the United States is the establishment of diversionary programs known as drug courts. Among other things, drug courts are an attempt on the part of the legal system to focus on substance abuse recovery, rather than on the merits of a given case. The mission of drug courts is to eliminate substance abuse and the resulting criminal behavior. Drug court is a “team effort that focuses on sobriety and accountability as the primary goals” ( NADCP, 1997 , p. 8). The team of professionals generally includes the state attorney, a public defender, pretrial intervention or probation staff, treatment providers, and the judge, who is considered the central figure of the team.

Drug courts have generally processed offenders in one of two ways: (1) through the use of deferred prosecution, by which adjudication is deferred and the defendant enters treatment, or (2) through a post-adjudication process, by which the case is adjudicated but sentencing is withheld while the defendant is in treatment ( U.S. General Accounting Office, 1997 ). In each case, the judge may reduce or eliminate criminal penalties if a defendant completes a drug court program which includes a substantial treatment component. A major reason for drug courts’ success is the power of the court to compel treatment.

A review of the research on drug courts indicates that they are at least as effective as other diversionary programs ( Belenko, 2002 ;  ONDCP, 1996 ), at least for adults. However, these courts have gradually moved from targeting low level and first time offenders to focusing on those whose substance abuse and criminal activity may be more serious and pose a greater threat to society—and a greater challenge to drug courts ( NIJ, 2006 ).There is less consensus on the effectiveness of juvenile drug courts, which are still experimenting with both prevention and diversion strategies ( NIJ, 2006 ). There were 2,301 Drug Courts in operation as of December 31, 2008 ( NDCI, 2009 ).

Needle and Syringe Exchange Programs

Needle exchange programs (NEPs) and syringe exchange programs (SEPs) are particularly controversial because of some individuals’ views that they promote drug abuse and addiction rather than direct users to the goal of abstinence. NEPs generally make clean needles available without pressuring users to accept other health and social services. In a recent U.S. survey, 94 percent of programs indicated that they do refer clients to drug treatment programs, but many do so selectively so as not to alienate clients who would otherwise use NEP services (CDC, 2001). More than a decade ago, a study conducted through the  U.S. General Accounting Office (1993)  lent qualified support to NEPs and SEPs, and the Secretary of the U.S. Department of Health and Human Services has agreed that research indicates that NEPs can be useful in preventing the transmission of HIV and other blood borne infections and that they do not encourage illegal drug use ( “Needle Exchange Programs,” 1998 ). However, this is such a politically charged issue that the federal government still has not lifted the ban on the use of federal funds for NEPs, saying that it prefers to leave it to states and communities to decide the issue.

Two types of laws impede needle exchange programs ( Lurie et al., 1993 ). In the vast majority of states, drug paraphernalia laws make it illegal to manufacture, possess, or distribute injecting equipment for nonmedical purposes. And in some states, prescription laws require a doctor’s prescription to purchase such equipment. Many NEP staff and volunteers believe that they are providing a life-saving service to those who would use drugs anyway, but in many cases, they risk arrest to do so.

A survey of SEPs conducted by the Beth Israel Medical Center in New York City in conjunction with the North American Syringe Exchange Network (NASEN) indicated that the number of SEPS is growing (CDC, 2001). Of the 113 members of NASEN, 100 (89 percent) participated, representing 80 cities, 30 states, the District of Columbia, and Puerto Rico. Four states—California, New York, Washington, and Connecticut—provided 52 percent of the programs. Of the SEPs, 96 reported exchanging a total of approximately 17.5 million syringes in 1997. Based on whether the state in which the SEP was provided had a prescription law or the program was covered under an exemption to the law, 52 of the SEPs were legal, 16 were illegal but tolerated (due to approval from a local body, such as a city council), and 32 were illegal (underground). In descending order, the programs operated in the following ways: syringe pickup/dropoff sites, storefronts, vans, sidewalk tables, on-foot outreaches, cars, locations where users gather (such as “shooting galleries”), and health clinics. (Some used more than one method.) Almost all the SEPs provided other services, as well. In descending order, they are condoms and dental dams (99 percent), information on safer injection techniques and/or bleach to disinfect injection equipment (96 percent), referrals to drug treatment programs (94 percent), on-site health care services (including HIV testing and counseling) (64 percent), tuberculosis skin testing (20 percent), screening for sexually transmitted diseases (20 percent), and primary health care services (19 percent).

Although many people believe that NEPs/SEPs offer humanitarian assistance by preventing HIV transmission and providing other life-saving services, the United States is still a long way from the stance that other countries have taken to promote needle exchange programs. For example, Denmark, France, Germany, and The Netherlands have experimented with vending machines that sell clean syringes or exchange dirty syringes for clean ones ( Lurie et al., 1993 ). Professionals that help individuals with alcohol and other drug problems should, of course, be committed to the highest ethical standards when assisting clients in determining the course of their treatment (see  Chapter 5 ). Given the many people who go untreated and the high relapse rates even among those who seek help, it is critical that professionals remain open to scientific investigation that might lead to improved methods of helping individuals eliminate, moderate, or otherwise reduce the negative consequences of alcohol and drug use. Although the point is debatable, some believe that we are becoming more open-minded about alternative approaches to addiction ( Connors, 1993 ;  de Miranda, 1999 ). Removing the ban on federal funding for these programs, as mentioned earlier, may eventually stimulate their expansion ( IHRA, 2010 ).

Chapter 9 Treating Substance-Abusing Youth

Katherine L. Montgomery and David W. Springer

University of Texas at Austin

There are no simple explanations as to why youth use licit and illicit drugs ( Wills, Sandy, & Yaeger, 2000 ), nor is it clear that most drug-using youth meet the diagnostic criteria to justify a diagnosis of alcohol or drug dependency. Thus, social workers should guard against the casual acceptance of substance abuse or dependency diagnoses in youth. In part, the problem is one of definition. As discussed in earlier chapters, serious definitional problems exist in assessing substance abuse and dependency. With youth, in particular, these diagnoses may become a prophecy of lifetime difficulties. On the other hand, ignoring symptoms of a youth’s substance abuse difficulties constitutes negligence. Thus, it is important for social workers to approach substance-abusing youth with a well-informed balance of purposeful action and caution.

The Monitoring the Future Study is a series of annual surveys of about 50,000 students in over 400 public and private secondary schools nationwide that has been conducted since 1975 by the University of Michigan Survey Research Center. According to the most recent report ( Johnston et al., 2009 ) from 2008, adolescent substance use has been slowly declining in recent years, but is still of great concern. The 30 day prevalence of using any illicit drug was highest among 12th graders (22 percent), followed by 10th graders(16 percent). With the emergence of prescription medication abuse around the turn of the twenty-first century, researchers have begun recording the use of Ritalin, OxyContin, Vicodin, and over the counter cough/cold medicines. The use of Ritalin and cough/cold medicines parallels the overall decline in substance use; however, OxyContin and Vicodin use remain fairly steady. Other drugs that held steady overall in 2008 include marijuana (21.5 percent), inhalants (6.4 percent), hallucinogens (3.8 percent), LSD (1.9 percent), PCP (12th grade only—1.1 percent), ecstasy (MDMA) (2.9 percent), sedatives (12th grade only—5.8 percent), tranquilizers (6.3 percent), and heroin (0.8 percent). Substances on the decline include amphetamines (5.8 percent), cocaine (2.9 percent), crack (1.3 percent), steroids (1.1 percent), cigarettes (33.1 percent), and alcohol (48.7 percent).

Johnston and colleagues (2009)  note that the 2008 data reflect two important themes. The first theme is a reflection of the substance use decline. They note that all percentages in 2008 are below the peak percentage from past years. The second theme, however, is one of caution. The authors point out that the “nation must not be lulled into complacency” (p.  9 ). They explain that the nationwide prevention programs seem to be working, and to keep substance abuse on the decline, the continuity of these programs is essential. According to the National Household Survey on Drug Abuse ( SAMHSA, 2008 ), 9.7 percent of persons age 12 to 17 were binge drinkers in the year 2007, and 2.3 percent were heavy drinkers. 1  Thus, while there is reason to be optimistic regarding substance use in the United States, abuse of substances continues to be problematic for youth. (See  Chapter 2  for more detailed information on the epidemiology of drug use and abuse.)

This chapter will provide a primer on walking the fine line between an uncritical acceptance of unwarranted labels and negligent practice. To accomplish this goal, the chapter examines substance abuse treatment for youth from the perspectives of risk and protective factors, thorough biopsychosocial assessment pertaining specifically to youth, and evidence-based treatment modalities.

Risk and Protective Factors

A substantial amount of research has been conducted on the concepts of risk and protective factors within developmental and contextual domains ( cf. Carbonell, Reinherz, & Giaconia, 1998 ;  Fraser, 2004 ;  Hodge, Cardenas, & Montoya, 2001 ;  Jenson, Anthony, & Howard, 2006 ) that either increase or decrease an adolescent’s likelihood of using substances. According to  Howell (2003) , “risk factors are those elements in an individual’s life that increase his or her vulnerability to negative developmental outcomes and also increase the probability of maintenance of a problem condition or digression to a more serious state” (p.  104 ). More simply stated, particular factors can increase one’s risk for negative outcomes. Conversely, protective factors are internalizing and externalizing factors that assist youth in guarding against social problems such as substance use ( Kirby & Fraser, 1997 ). It is believed that the greater number of protective factors present, the less likely the youth is to engage in substance use.

Worth noting is the fact that adolescents displaying particular risk factors are not assured to use substances, but are simply at greater risk than those not displaying the specific risk factor(s). Conversely, some adolescents possess multiple risk factors and never use substances. Researchers have explored explanations as to why, despite having or not having particular risk and protective factors, some youth chose to use substances and others do not. One conclusion currently offered in the literature is the concept of resiliency ( Turner, 2001 ). Resiliency is defined as “the remarkable capacity of individuals to withstand considerable hardship, to bounce back in the face of adversity, and to go on to live functional lives with a sense of well-being” ( Turner, 2001 , p. 441).  Vaillant (1993)  metaphorically presents resiliency as “the capacity to be bent without breaking and the capacity, once bent, to spring back” (p.  248 ). Understanding resilience and protective factors in youth assists in explaining why some youth can overcome adversity and seemingly live normal lives while other youth succumb. While there is no simple formula for predicting the effects of drug use on youth, it is indisputable that reducing risk factors and increasing protective factors are beneficial for adolescents. Researchers typically categorize each of the factors within specific domains: individual, peer, family, school, and community (see  Table 9.1 ). Selected factors among each domain will be explored in the following section.

Individual Factors

How an adolescent responds to external factors greatly varies between individuals. Two siblings may encounter very similar environments, yet make vastly different choices. There are multiple individual factors that contribute to a youth’s risk of substance use: youth’s perception of substance abuse, delinquency, antisocial behavior, rebelliousness, and sensation-seeking ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  NIDA, 2003 ;  SAMHSA, 2001 ). As some of the factors are explored further, the reciprocal and cyclical nature of risk factors can be observed.

Perception of Risk

Youth who perceive substance use to be harmless are much more likely to use substances ( SAMHSA, 2000 ). For example, youth believing marijuana to be less dangerous than smoking cigarettes often use this rationale as a motive to smoke marijuana. Additionally, a youth’s misperceptions about how others perceive drug use and misuse may pose a hindrance to successful treatment ( Christiansen, Goldman, & Inn, 1982 ). If, for example, a youth believes that others are morally critical of him or her, acrimonious arguments may ensue. On the other hand, if a youth thinks of drug use and misuse as a disease, then it might eliminate some of the acrimonious arguments but encourage irresponsible, “I’m-not-responsible-because-I’m-sick” statements. In any event, understanding how the youth perceives others’ evaluations of him or her may provide useful insights.

TABLE 9.1 Substance Use Risk and Protective Factors

Domain	Risk Factors	Protective Factors
Individual	Perception of risk of substance abuse Delinquency Early and persistent antisocial behavior Rebelliousness Favorable attitudes toward substance use Sensation-seeking	Religiosity Resilient temperament Social skills Belief in moral order
Peer	Friends’ attitudes toward substance use Friends’ use of substances Gang involvement	Friends who engage in conventional behavior
School	Poor attitude toward school Academic failure Lack of commitment to school	Recognition for involvement in prosocial activities Anti-drug use policies School opportunities for prosocial involvement
Community	Drug Availability Community laws and norms favorable to drug use, fire arms, and crime Transitions and mobility Low neighborhood attachment Community disorganization	Community opportunities for prosocial involvement Community recognition for prosocial involvement
Family	Poor family management Lack of parental supervision Parental attitudes toward substance use Family history of substance use Parental attitudes favorable toward antisocial behavior Family conflict	Family attachment Family opportunities for pro-social involvement Family recognition for pro-social involvement

Note: Adapted from  SAMHSA, 2001 ;  NIDA, 2003 ; and  Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 .

Delinquency

It is well documented that there are many similarities in the risk and protective factors for juvenile delinquency and substance use ( Hawkins, Catalano, & Miller, 1992 ;  Jenson, 1997 ;  Williams, Ayers, Abbott, Hawkins, & Catalano, 1999 ;  Rivaux, Springer, Bohman, Wagner, & Gil, 2006 ).  Williams et al. (1999)  notes six factors that predict both juvenile delinquency and substance abuse: moral beliefs, peer influence, school attachment and commitment, family relationships, academic achievement, and social skills. Thus, youth who are at high risk of using substances are often at high risk of becoming delinquent. Implications for delinquency in assessment are explored later.

Protective Factors

Individual protective factors include religiosity, resilient temperament, social skills, and belief in moral order ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  NIDA, 2003 ;  SAMHSA, 2001 ). Most individual protective factors coalesce around an adolescent’s belief system and the lens through which they view the world. Crucial to the process of molding ones belief structure, however, are peers and the family system. The way youth view the world is often an indication of how they are influenced by those around them.

Peer Factors

As youth move through developmental changes, they often rely on the perceptions and choices of others to guide their behavior. Risk factors associated with youth’s peers are: friends’ attitudes toward substance use, friends’ use of substances, and gang involvement ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  NIDA, 2003 ;  SAMHSA, 2001 ). When youth observe specific behaviors as normative in a group setting, it is not difficult for the adolescent to adapt to a shared belief. Conversely, having peers that engage in normative behavior serves as a protective factor. Prevention efforts allowing youth opportunities to engage in healthy relationships are necessary for youth.

Family Factors

Whether it is the level of home stability, abuse or neglect, or with whom the youth lives, the impact of the family system is great. Factors within the family domain recognized as placing a youth at risk of using substances are: poor family management, lack of parental supervision, parental attitudes favorable toward the use of substances, family history of substance use, family conflict, and family attitudes favorable toward antisocial behavior ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  NIDA, 2003 ;  SAMHSA, 2001 ). Families being involved and bonding with their youth often serve to protect them from the risk of using substances.  Ford (2009)  found that the absence of family bonding was significantly correlated with nonmedical prescription drug use. Thus, as will be further explored next, interventions designed to treat the family system are of great value when treating substance abusing and dependent youth.

Family History of Substance Use

In a longitudinal analysis, Hops and colleagues found that parental substance use strongly predicted children’s likelihood of using substances ( Hops, Duncan, Duncan, & Stoolmiller, 1996 ). In another example, having alcoholic parents presents is a significant risk factor associated with the offspring’s development of alcohol dependency ( Leukefeld, McDonald, Stoops, Reed, & Martin, 2005 ). Again, as youth become to recognize substance use as normative among the systems they encounter, the risk of using substances increases.

Family Conflict

Youth raised within stable family systems are less likely to use substances ( Buu, DiPiazza, Wang, Puttler, Fitzgerald, & Zucker, 2009 ). Discussed further in the assessment section, youth often cope with familial conflict by using substances. They are additionally drawn to peers who are seeking the same escape from conflict. When parents struggle with consistency, managing their own behavioral difficulties, and positively engaging their youth, their child becomes at risk.

School Factors

In addition to the family system, a youth’s school experiences form the attitudes and often provide the market that allows drug use or a meeting place for youth who engage in drug use as asocial activity ( Smith, Koob, & Wirtz, 1985 ). Risk factors in the school domain include: youth’s poor attitude toward to school, academic failure, and lack of commitment toward school ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  SAMHSA, 2001 ). During childhood and adolescence, the importance of social activity among peers cannot be overemphasized. Youth observe, learn, and speak with each other and by so doing become socialized into the common culture. Activities that include drug use may interfere with educational activities in two ways. First, performance in the classroom may suffer. Documentation of the problems caused by drug use is widespread. Recent scientific research provides overwhelming evidence that drugs interfere with normal brain functioning and have long-term effects on brain metabolism and activity ( NIDA, 2001 ). Second, drug use is associated with conflict. Although conflict is not inevitable with drug use, it can occur with alarming frequency. For instance, disputes over payment and extortion to secure payment for drugs can result in violence that reduces confidence in the safety of the school setting for all students. Prevention efforts to increase protective factors (recognition for involvement in prosocial activities, anti-drug use policies, and school opportunities for prosocial involvement:  Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  SAMHSA, 2001 ) are necessary.

Community Factors

Of the five domains, the community domain is the area with the least amount of research ( Farrington, 2000 ). Drug availability, community norms favorable to drug use and crime, transitions and mobility, low neighborhood attachment, and community disorganization are all identified as community level factors that place a youth at risk of using substances ( Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004 ;  SAMHSA, 2001 ). Different from adults, youth are required to experience great transitional changes as they move from the security of home to school. Research has shown that as children progress through educational transitions, they are at greater risk of using substances ( NIDA, 2003 ). While macro-level prevention and interventions are in their infancy ( Thyer, 2008 ), it is important for social workers to keep a macro-level perspective of what might influence or provide protection against substance use.

Social workers gain benefit from understanding risk and protective factors. The first benefit is assistance in assessment. In a thorough biopsychosocial assessment, social workers can utilize risk and protective factors to identify existing or potential substance use concerns. For example, if a parent describes their own struggle or acceptance of substances, the interviewer can explore substance use with the adolescent. A second benefit is with regard to treatment planning. The social worker can support the youth and family in making goals to change specific risk factors. By reducing risk factors and assisting families in building protective factors, the social worker can assist their client and the family in potential substance use prevention.

Assessment with Substance-Abusing Youth

Assessment is the first active phase of treatment ( Springer, McNeece, & Arnold, 2003 ). Without a thorough and complete assessment, the social worker cannot develop a treatment plan that will serve the youth and his or her family. Assessment and diagnosis with substance-abusing clients is covered in  Chapter 5 ; however, proper youth assessment requires additional, specific areas to be explored. A social worker hoping to positively impact youth struggling with substance use must first understand how youth differ developmentally and contextually when choosing and implementing treatment. Information gathered from a youth’s educational, legal, and family history will often look dramatically different than an adult’s completed assessment and specific factors must be considered. Such contexts provide social workers with the necessary background in treatment planning and undertaking drug and alcohol interventions. Although drugs have specific physiological effects, their use and meaning derive from biological, psychological, and sociological contexts. It is not possible to understand substance abuse in youth without considering these biopsychosocial contexts in assessment. Failure to assess any one of the systems accurately can result in ineffective treatment that leaves the youth vulnerable to increased alcohol and drug use and the family angered by insensitive practice.

In an ideal setting, information is gathered from both the parent (s) or guardian (s) and the youth. Studies have shown that there is little agreement between youth and parental reports during assessment ( Israel, Thomsen, Langeveld, & Stormark, 2007 ). Typically, both have offered truthful information that provides the social worker with a broader, clearer perspective. Adolescents are often untruthful with parents, particularly in regard to illegal behavior and social problems. If possible, it is important that assessments be conducted separately, by the same professional. In first gathering information from the parent, the social worker can understand valuable developmental history the youth often does not know. Parents can provide detail the youth either do not know or are not comfortable sharing. Using the parent’s assessment information, the social worker can approach the youth interview with a contextual background. It is important to allow the parent’s interview to assist with the youth’s assessment; however, one should take caution and use appropriate clinical skills so as to not allow a parent’s perspective to overshadow the voice of the youth. In addition to assessing accurately the adolescent’s understanding of others’ perceptions, the social worker should examine the meaning of the drug to the youth. Their understanding or relationship to drugs can frequently assist the social worker in planning treatment. ( Chapter 2  addressed addicts’ expectations about the effects of drugs.) When youth expect and receive a specific effect, they may come to trust the drug and perceive it as a friend. In particular, a youth who may not have other friends may consider a drug to be his or her best friend. As a result, sadness is a natural consequence of drug use cessation. Treatment that focuses on resolution of the grief that follows a significant loss should be initiated.

Education

A youth’s educational assessment will often reveal what an adult’s occupational assessment would. Similar to occupational assessments in adults, educational information can illuminate patterns of truancy, level of engagement in day-to-day responsibilities, and ability to function in social settings. For youth, there is often a shift in educational behavior that mimics a choice to begin using substances on a frequent basis. As a youth begins using substances, they are more likely to have diminished success in school ( Bachman, O’Malley, Schulenberg, Johnston, Freedman-Doan & Messersmith, 2007 ). Thus, when assessing the educational domain, the social worker can inquire about changes in grades, history of disciplinary behavior, and level of engagement in school to ascertain potential timeline for substance use.

Legal History

Due to the manner in which youth use substances, whether it be smoking cigarettes, drinking alcohol, taking their mother’s prescription medication, or smoking marijuana, it is often against the law and they are thus at risk of engaging with the juvenile justice system. In a study of juvenile detainees, 56 percent of males and 40 percent of females tested positive for an illegal substance at the time of their arrest ( National Institute of Justice [NIJ], 2003 ). Social workers assessing youth who use substances should inquire about their legal context. Are they currently on probation? If so, it is not uncommon for many states to provide therapeutic intervention as a requirement of probation. In a thorough assessment, it is important to gather information regarding treatments they may have received. Often, previous experiences will shape the lens through which they initially perceive future relationships with social workers and therapists.

Family History

With adult assessment, family history is often gathered to inquire history about substance use or psychiatric illness displayed in the immediate and extended family system. With youth, however, substances are often used as a coping strategy to survive amongst their family system. As discussed in the risk factors, youth coming from families involving high levels of conflict are likely to abuse substances. It is important that the social worker inquire about the communication and problem-solving strategies within a family system. If youth are not allowed or do not appropriately communicate difficult feelings, they will often turn to substances for self-medication.

Standardized Instruments

A necessary component to adequate assessment is the use of standardized instruments. There are several instruments currently utilized with evaluation of substance abusing youth.  Table 9.2  provides selected standardized instruments that may be useful in assessment with substance-abusing youth. (For a more comprehensive review of assessment tools for youth, see  Fischer and Corcoran [2007] ;  Shaffer, Lucas, and Richters [1999] ; and  Springer, [2002a] .)

Having mentioned the importance of standardized assessment tools, a word of caution is in order: It is ill advised for a practitioner to rely solely on self-report measures when determining diagnostic impressions and a course of treatment for youth. Youth can easily present themselves as they wish to be perceived by others on such measures. Thus, clinical decisions should be supplemented by a thorough biopsychosocial history (which should include information gathered from external sources such as parents, physicians, and teachers, when at all possible), a mental status exam (when appropriate), and direct observation of the client. The timeline follow-back procedure( Sobell & Sobell, 1992 ) should be included in the assessment of substance abuse history with adolescents ( Waldron, 1997 ). This structured interview technique samples a specific period of time using a monthly calendar and memory anchor points to help the client reconstruct daily use during that period. This may offer the most sensitive assessment for adolescent substance abusers ( Lecesse & Waldron, 1994 ).

Liability

TABLE 9.2 Assessment Tools for Substance Abusing Adolescents

Assessment Tool	Website
Problem Oriented Screening Instrument for Teenagers (POSIT)	www.nhtsa.dot.gov/people/injury/alcohol/juvenile/posit.pdf
Drug Use Screening Inventory-Revised (DUSI-R)	pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/InstrumentPDFs/32_DUSI-R.pdf
Child and Adolescent Functional Assessment Scale (CAFAS)	www.cafas.com/
Substance Abuse Subtle Screening Inventory for Adolescents (SASSI-A2)	www.sassi.com/
Massachusetts Youth Screening Instrument Version 2 (MAYSI-2)	www.maysiware.com/MAYSI2.htm
Voice Diagnostic Interview Schedule for Children (Voice DISC)	www.promotementalhealth.org/voicedisc.htm

The threat of litigation significantly affects practice decisions. More than ever, social workers must be cognizant of clients’ expectations and up-to-date practice wisdom. When youth are brought for treatment, their parents frequently expect social workers and other service providers to employ professional methods to remedy their child’s social, psychological, and familial problems. Despite parents’ inclination to believe therapy can “fix” their child ( Kazdin, 2005 ), social workers do not have any single intervention that can dramatically “cure” youths’ substance use and abuse. Alcohol and drug treatment in the United States is heavily influenced by twelve-step programs. Since members sometimes make dramatic claims of these programs’ success, social workers should carefully explain the limitations of available treatment. Otherwise, parents may expect dramatic and lasting results from treatment and may be angered and disheartened by failure ( Michels & Cooper, 1997 ). Parents must also understand their roles in treatment; otherwise, they may become increasingly vocal in their complaints about progress. As a partial remedy to these legal pitfalls, social workers must avoid endorsing treatment methods that run counter to published literature regarding evidence-based practice.

In any event, the youth’s legal standing must be considered when planning treatment. Although the age of consent varies from state to state, parents and guardians must give explicit consent before treatment can begin with minor children. The social worker should examine closely agency guidelines on who can give informed consent for what procedures before undertaking treatment. Drug-abusing youths’ relationships with parents and/or guardians may be strained, providing fertile ground for misunderstandings. By remembering that youth may in many cases be unable to give informed consent to proceed with treatment, social workers should from the very start incorporate parents into treatment planning and implementation ( Springer, 2002b ).

It is not always clear if a youth has been coerced into treatment. The level of compliance with treatment directives may in part hinge on the social worker’s precise understanding of who initiated and who has interest in the treatment. When parents initiate their youth’s entry into treatment, the social worker will be faced with the unenviable task of gaining the youth’s cooperation.

Treatment with Substance-Abusing Youth

The treatment modalities discussed in this chapter are by no means the only ones available to treat substance-abusing youth. Because treatment modalities vary so widely in their implementation, it is difficult to state with full confidence that any one type of treatment is particularly more effective with adolescents than others. In considering what type of treatment modality is best suited for preventing and remediating a youth’s problems, the social worker should consider many issues in addition to reputed effectiveness. Cost, predicted compliance with treatment procedures, and level of family involvement are also important. The choice of treatment methods must take into account their degree of intrusiveness.

Primary prevention efforts that consist solely of educational efforts addressing risk and protective factors are the least intrusive, require the least involvement, and can be implemented in many settings (see  Chapter 7 ). Outpatient treatment and community self-help groups (e.g., Alcoholics Anonymous) are the next level (see  Chapter 6 ). More intensive, and client-centered approaches, also include family therapies designed to meet the unique needs of the family system (see  Chapter 10 ).From a systems approach, the youth using substances is only a part of what contributes to the illness. As previously explored, various domains each play a role in placing a child at risk of using substances. Inpatient treatment, which is usually implemented in a hospital setting, is a third level of treatment. The last and most intrusive level of treatment is residential treatment and treatment communities. In the last few years, this level has been used less commonly to treat substance-abusing youth and has been replaced more frequently by outpatient efforts. In fact, a dual diagnosis of substance abuse or dependence and mental illness is often required to warrant payment of inpatient or residential treatment from a third-party payer. In addition to lower costs, less intrusive treatment methods generally require less family involvement and less disruption in day-to-day activities. More intrusive treatment methods are much more expensive and typically better suited when there is a medical risk, danger of suicide or homicide, or uncontrolled behavior that might result in harm to self or others.

Dual Diagnoses

Sixty percent of adolescents who either use, abuse, or have become dependent on substances have a diagnosable mental health illness ( Armstrong & Costello, 2002 ). The co-occurrence of severe emotional difficulties and drug abuse is not a coincidence (see  Chapter 13 ). Adolescents may use drugs as a means of coping with the tribulations that they experience. For other youth, drug use exacerbates serious emotional disorders. There are specific mental health illnesses that often pertain to substance-abusing youth. Studies suggest a prominent role for substance use in the etiology and prognosis of psychiatric disorders such as mood disorders, conduct disorder, attention-deficit/hyperactivity disorder, and anxiety disorders ( McBride, VanderWaal, Terry, & VanBuren, 1999 ). Conversely, psychiatric disorders also appear to play a crucial role in the etiology of and vulnerability to substance use problems in youth ( Armstrong & Costello, 2002 ;  Hawkins, Catalano, & Miller, 1992 ). Thus, the presence of substance abuse and dependency in youth may be a harbinger of serious emotional difficulties. Treatment should address both conditions concurrently.

Bender, Springer, and Kim (2006)  conducted a systematic review on the effectiveness of current empirically supported treatments for dually-diagnosed adolescents. Studies included in this review were those that met the following selection criteria established by the researchers:

1. randomized clinical trials, allowing researchers to determine effectiveness;

2. treatment for dually-diagnosed disorders, meaning treatment for both substance abuse and mental health disorders concurrently;

3. peer reviewed in past 10 years, to provide the most current literature available;

4. treatments designed for youth with already existing dual diagnoses, excluding prevention studies;

5. studies published in English; and

6. treatment for youth ages 12 to 18, narrowing studies to those of adolescents only.

The search identified seven interventions for dually-diagnosed adolescents reported across six different studies that met these selection criteria. These included: Multisystemic Therapy (MST;  Henggeler, Pickrel, & Brondino, 1999 ), Interactional Group Treatment (IT;  Kaminer, Burleson, Blitz, Sussman, Rounsaville, 1998 ;  Kaminer & Burleson, 1999 ), Family Behavior Therapy (FBT;  Azrin, Donohue, Teichner, Crum, Howell, & DeCato, 2001 ), Individual Cognitive Problem-Solving (ICPS;  Azrin, Donohue, Teichner, Crum, Howell, & DeCato, 2001 ); Cognitive Behavior Therapy (CBT;  Kaminer, Burleson, & Goldberger, 2002 ), Ecologically Based Family Therapy (EBFT;  Slesnick & Prestopnik, 2005 ), and Seeking Safety Therapy (SS;  Najavits, Gallop, & Weiss, 2006 ).

The results were analyzed and interpreted using a statistic called an effect size. This statistic is commonly used in clinical outcome research. Effect size statistics portray the strength of association found in any study, no matter what outcome measure is used, in terms that are comparable across studies ( Rubin & Babbie, 2008 ). Thus, they enable us to compare the effects of different interventions across studies that use different types of outcome measures. These treatment effects are interpreted as large, moderate, or small, which is simply a way to more easily interpret the effect size.

TABLE 9.3 Ten Preliminary Treatment Guidelines for Dually-Diagnosed Adolescents

1. Assessment is multi-pronged, ongoing, and includes practitioner, parental and self monitoring so that treatment is responsive to the changing needs of the client. 2. Treatment strategically enhances engagement and retention. 3. Treatment plans are flexible and allow for client choice and voice. 4. An integrated treatment approach is used to address both mental health and substance related disorders concurrently. 5. Treatment is developmentally and culturally sensitive to match the unique needs of the client system. 6. Treatment is ecologically grounded and systems oriented, including important individuals to the client such as family members, friends, and school personnel. 7. Treatment taps several domains of the client’s functioning to enhance the client’s problem solving and decision-making skills, affect regulation, impulse control, communication skills, and peer and family relations. 8. Treatment is goal-directed, here-and-now focused, and strength-based. 9. Treatment requires active participation by all members involved, and includes home work assignments. 10. Interventions aim to produce sustainable changes over the course of treatment.

Source: From “Treatment Effectiveness with Dually Diagnosed Adolescents: A Systematic Review” by Kimberly Bender et al. from Brief Treatment and Crisis Intervention 6(3), 2006, p. 200. Reprinted by permission of Oxford University Press.

Substance abuse effect sizes were large for the FBT, ICPS, PET, and CBT groups. Worth noting is that EBFT and SS also had moderate effect sizes at posttest and sustained moderate reductions in substance abuse at follow-up. While analysis identifying effective treatment modalities for individual outcomes is helpful, one challenge of treating dually-diagnosed youth is their likely diagnosis with several or all of these conditions. Reviewing these results, FBT and ICPS appeared to be the only interventions to produce large treatment effect sizes across externalizing, internalizing, and substance abuse domains. Furthermore, the large effect sizes for these two treatments were evident at nine-months post-treatment, demonstrating sustainability of effects over time.

After examining the common factors among treatments with demonstrated effectiveness, Bender and colleagues developed ten preliminary treatment guidelines for dually-diagnosed adolescents (see  Table 9.3 ). These guidelines might serve as a barometer, perhaps providing a general gauge of how to tailor treatment for dually-diagnosed adolescents.

Prevention and Drug Education

The current literature on the treatment of drug use, misuse, and dependency emphasizes the complexity of preventing adolescent substance abuse. Indeed, research on factors and processes that increase the risk of using drugs or protect against the risk of using drugs has identified a range of primary targets for preventive intervention: family relationships, peer relationships, the school environment, and the community ( Physician Leadership on National Drug Policy, 2002 ). Successful prevention programs “will wisely address developmental as well as parental and community factors that influence drug use among high-risk youth” ( Schinke & Cole, 1995 , p. 228). In other words, they will use risk and protective factors from each domain to guide prevention efforts.

Such recommendations, however, only highlight the conceptual quagmire of primary, secondary, and tertiary prevention strategies (see  Chapter 7 ). Of the three strategies, only primary prevention is intended to prevent non-using youth from beginning substance use. There is an increasing consensus that primary prevention efforts must focus on family and school environments to increase children’s self-esteem and self-efficacy ( Kumpfer & Turner, 1990–1991 ;  Schaffer, Phillips, Enzer, Silverman, & Anthony, 1989 ). Secondary and tertiary prevention (also known as treatment) address problems of youth that are caused by varying degrees of drug involvement. Both these types of prevention strategies focus on encouraging a cessation of drug use, remediating problems, and strengthening the youth’s resilience ( McNeece & Springer, 1997 ). However, prevention works best when there is a clear target for intensive efforts. Unfortunately, there is no clear profile for identifying youth who are at greatest risk for debilitating substance use ( Johnson, 1990–1991 ), although much research is being done in this area.

Many alcohol and drug intervention programs developed for children and adolescents are implemented within the school setting and taught by adult authority figures. Studies comparing teacher-led and peer-led prevention interventions have resulted in mixed findings ( Erhard, 1999 ). Some of the assumptions about peer-led models, such as the fear of control/discipline difficulties, are unfounded ( Erhard, 1999 ), and peer-led programs have yielded twice as much student self-disclosure among participants ( Erhard, 1999 ). All in all, there are strong indications that the peer-led model may possess greater potential for primary prevention than the teacher-led model.

Historically, drug prevention has most commonly consisted of the information-education approach, which assumes that once adults make adolescents aware of the health hazards of substances, they will develop antidrug attitudes and subsequently make choices not to use. Research that questions the effectiveness of information-only prevention programs found that not only did this form of intervention fail to produce reduction in drug use, but some programs led to a subsequent increase in the use of substances ( Botvin, 1995 ;  Dryfoos, 1993 ;  Falck & Craig, 1988 ).

The contributions of social theorists (cf.  Bandura, 1977 ;  Jessor & Jessor, 1977 ;  McGuire, 1968 ) led prevention model developers to consider the interplay of individual, social, and environmental factors ( Falck & Craig, 1988 ). These models incorporate the complex, multilevel interaction of children with their environment and social and family systems. Ecological models stress the concept of multiple levels of influence on child development and the complex interaction of child and environment ( Tolan, Guerra, & Kendall, 1995 ). They focus on social skills and general functioning, rather than on the avoidance of substance use alone. In addition, drug-resistance strategies training are considered an important component of prevention.

Schinke, Orlandi, and Cole (1992)  conducted an evaluation of the effectiveness of participatory substance abuse prevention programs in Boys and Girls Clubs (BGC) located in selected public housing projects. They found that public housing projects that received such prevention services through BGC had less drug-related activity, less damage to housing units, and increased parental involvement in youth activities. These results are consistent with findings that youth benefit from school-based prevention and treatment programs that invite parents and significant others in youth’s lives to participate in treatment planning and delivery ( Smith, 1985 ).

Traditionally, drug education has consisted of school- and district-wide teaching efforts. Early drug education involved attempts to intimidate youth from any use of any illicit drug. In general, drug education embodied didactic presentations that described the drug, its use, and the consequences of its use. Such efforts were generally aimed at public school settings, in which public school teachers or other designated school staff were given a packet of materials to present to classes or to assemblies of students. In early drug education efforts, both the message and the presenter frequently provided a skewed picture of drug use and misuse.

For example, marijuana was described as causing psychotic decompensation, juvenile delinquency, and other catastrophic consequences. When youth experimented with marijuana and failed to experience these dire consequences, they questioned the credibility of scare-oriented drug education. Traditional drug education also failed because its messages were designed to scare passive participants into compliance. In many circumstances, older students were well versed in the use of drugs and had not experienced significant consequences. Younger students were intrigued by the presentations and, in some cases, became more interested in drugs as a result of the drug education attempts.

In retrospect, one mistake of early prevention efforts was to rely on a didactic approach in a setting in which teachers may not have been perceived as credible role models. Further, some teachers might have engaged in recreational use and were undoubtedly ambivalent about presenting materials that seemed incorrect. The lesson that became apparent by the beginning of the 1980s was that pure drug education campaigns needed revision, both in terms of their content and their media. The ineffectiveness of such drug education programs resulted in their becoming an object of derision in the 1960s and 1970s ( Smith, 1984 ).

Differing views regarding the effectiveness of drug education efforts continue to persist. Some drug educators have reported success when they employed credible information sources, avoided scare tactics, began drug education efforts in primary schools, and involved adolescents through the use of role-playing and problem-solving paradigms ( Smith, 1983 ). For additional information about the effectiveness of D.A.R.E. and other prevention programs, see  Chapter 7 .

Thus far, promising programs espousing social skills, effective resistance strategies, and ecological models have been implemented with youth ( Wilson, Rodrigue, & Taylor, 1997 ). At present, few prevention approaches have proven effective in reducing substance use among adolescents, and even fewer have been tested with youth of minority cultures ( Schinke & Cole, 1995 ). The most successful programs tend to be the most comprehensive and are tailored to the culture of the target population. Culture, in this respect, refers not only to racial/ethnic upbringing but also to the swiftly changing culture of youth. There is a need for cultural grounding and mechanisms to accurately ascertain such factors to create and facilitate effective prevention efforts. The reader is referred to SAMHSA’s website for the Center for the Advancement of Prevention (CSAP) Model Programs. 2  This resource is designed to bridge the gap between research and practice by developing and disseminating culturally grounded, evidence-based substance abuse prevention programs and policies.

Outpatient Treatment

As with many aspects of treatment for adolescent substance abuse, there are sharp disagreements on the usefulness of outpatient and community self-help programs. Although some writers believe that outpatient treatment is ineffective ( Wheeler & Malmquist, 1987 ), others argue that it is a viable option for adolescents. For example,  Semlitz and Gold (1986)  have outlined seven criteria that they believe will justify a recommendation for outpatient treatment:

1. Absence of acute psychiatric or medical difficulties

2. Absence of chronic medical difficulties

3. Willingness to abstain from all mood-altering drugs

4. Willingness to submit random urine screens

5. A history of successful outpatient treatment

6. Family investment and involvement in the treatment process

7. Evidence of self-motivation

Some examples of outpatient treatment techniques for youth include cognitive-behavioral skills training interventions and abstinence-oriented self-help programs. Skills-training models of treatment rely on learning theories to organize practice techniques. Skills-training techniques presuppose that behaviors, whether desired or not, are learned in some social setting. By the same logic, a behavior that is once learned can subsequently be unlearned.

Skills-training models teach youth behaviors that are incompatible with drug-using behaviors. Although some mention is made in passing about personal characteristics and how skills are taught, skills training have traditionally focused on what is taught, not how it is taught. Skills-training typically includes drug education, social skills training, and problem-solving approaches (i.e., improving faulty thinking).

Highlighted in this section will be two evidence-based treatments for working with substance-abusing youth. The first approach presented is the Adolescent Community Reinforcement Approach (A-CRA). This approach was initially found to be effective in adolescent outpatient treatment; however, in recent years it has been adapted for residential treatment setting implementation and has also been used as a family-based approach. Due to the origination of A-CRA, it will be highlighted here with outpatient treatments. The second approach to be discussed is Problem-Solving and Social Skills Training (PSST). PSST is an evidence-based approach that is used as a component in A-CRA ( Godly, Smith, Meyers, & Godley, 2009 ) and as a standalone treatment, which is how it is discussed below. For a more detailed exposition on either of these approaches, see  Springer and Rubin (2009) .

Adolescent Community Reinforcement Approach

A-CRA is a treatment initially adapted from Community Reinforcement Approach (CRA), an intervention strategy for adults with severe alcohol problems ( Azrin, 1976 ). While additional sessions may be added, A-CRA is typically offered one hour each week for 12 to 14 weeks ( Godley, Smith, Meyers, & Godley, 2009 ). Treatment guidelines specify a combination of three types of sessions: adolescent alone, parent/caregiver and adolescent, and parent/caregiver alone. Dependent upon the adolescent’s needs and the results of his or her happiness self-assessment, the therapist will choose one of17 strategies ( NREPP, 2008 ). Strategies include a variation of interventions such as problem-solving techniques, communication skills, job-seeking skills, and anger management ( NREPP, 2008 ). A-CRA is now listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP;  www.nrepp.samhsa.gov/ ).

Problem-Solving and Social Skills Training

PSST ( Spivak & Shure, 1974 ) is a cognitive-based approach designed to decrease disruptive and inappropriate behavior in youth. The therapeutic process encourages youth to use problem-solving techniques to address the harmful behavior by generating effective responses ( Springer, 2006 ). Multiple techniques are implemented to achieve therapeutic goals: modeling, feedback, practice, didactic teaching, teaching alternative behaviors, social reinforcement, role playing, and therapeutic games ( Kronenberger & Meyer, 2001 ). Springer and Lynch identify five specific steps therapists utilize in assisting their client to address problematic behavior: “1) defining the problem, 2) brainstorming, 3) evaluating the alternatives, 4) choosing and implementing an alternative, and 5) evaluating the implemented option” ( Springer & Lynch, 2009 ). PSST has been identified as a strong, empirically supported, treatment option in working with youth with disruptive and problematic behavior ( Springer & Rubin, 2009 ).

Abstinence-Oriented Approaches

Treatment models with a goal of abstinence dominate programs in the United States. These models are most closely associated with the Alcoholics Anonymous (AA) approach. It was originally designed for mature male alcoholics, however, and may be difficult for most youth to understand, let alone embrace. Although AA is geared toward adults, some communities are making efforts to provide youth with AA-type support groups.

Abstinence models require that social workers understand the three parts of twelve-step programs: surrender steps, integrity steps, and serenity steps ( Brundage & Bateson, 1985 ). The surrender steps consist of treatment personnel persuading youth that they cannot control their use of drugs. Youth surrender their attempts to control drug use to a higher power. The higher power is not always intended to be synonymous with God or any similar deity; rather, the emphasis is on creating a spiritual defense against drug use. The integrity steps focus on youth’s admitting that they have caused harm to others, thus enabling them to accept personal responsibility for the conflicts precipitated by tension around drug and alcohol misuse ( Brown-Standridge, 1987 ). Integrity steps also allow youth to apologize for difficulties that were caused by their drug and alcohol use. The last steps in the twelve-step program, serenity steps, are concerned with maintaining a drug-free life-style. While the surrender steps assist chemically dependent youth to cease use, the integrity steps begin the task of rebuilding relationships through apologies, and the serenity steps focus on living a life free of drugs and alcohol.

A critical treatment planning decision for practitioners to consider is which adolescents are more likely to respond positively to groups such as Alcoholics Anonymous and Narcotics Anonymous (NA). It is certainly standard practice for practitioners to refer substance-abusing adolescents to such groups. “These adolescents are not a homogeneous group, however, and it is important for clinicians to know which may benefit most from this type of referral” ( Hohman & LeCroy, 1996 , p. 350).

The Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) is one of the most extensive longitudinal databases on adolescent drug treatment outcomes to date ( Harrison & Hoffman, 1989 ). Results derived from interviews with 493 youth at 6- and 12-month follow-ups revealed that adolescents who remained in self-help groups (e.g., AA) for one year following treatment had better outcomes than those who attended occasionally or not at all (cited in  Jenson, 1997 ).  Alford, Koehler, and Leonard (1991)  found that AA benefited adolescents who were able to understand and accept its principles and traditions. Since there was no comparison group, these findings should be interpreted with caution.  Hoffman and Kaplan (1991)  found that family participation during treatment and in self-help groups following treatment were strongly correlated with adolescent abstinence and participation in AA. However, in a study that compared the characteristics of inpatient-treated adolescents who did and did not affiliate with AA,  Hohman and LeCroy (1996)  found just the opposite: that family participation was not predictive of an adolescent’s affiliation with AA. In fact, Hohman and LeCroy were better able to predict characteristics of adolescents who did not affiliate with AA than those who did. Those adolescents who had friends that used drugs, who had no prior treatment, and who experienced greater parental involvement in treatment were less likely to affiliate with AA.

The findings on which adolescents will benefit from groups such as AA are equivocal. They do, however, inform practitioners that not all substance-abusing adolescents benefit equally from affiliation with such groups. Accordingly, referring adolescents to AA and NA should be based on a thorough assessment and sound clinical decision making. Given the above findings, the blanket prescription of AA or NA groups for all adolescents who have used or abused alcohol or drugs is not a judicious use of resources, nor is it effective treatment planning.

Family-Based Treatments

It is a truism that families are critical in the youth’s chemical dependency treatment, and this should not be surprising. Not only do use and abuse cause family problems, but they may also be a method of coping with family conflict ( Bowen, 1974 ). One caveat, however, should be stressed: Because all families experience conflict and not all youth experience drug dependency, the social worker must be cautious in concluding that family conflict caused a child or adolescent to abuse drugs. Severe family conflict does create a context in which the likelihood of abusive drug use increases. But due to peer influences, adolescents begin to pull away from their families and form their own networks of friends and acquaintances. Although a thorough family assessment generally should be conducted, the clinical assessment of an adolescent may also require considering the network of friends when planning treatment ( Smith, 1985 ;  Springer, 2002b ).

Several models of family therapy are available for working with substance-abusing youth and their families. Models that have gained empirical support for assisting substance-abusing youth will briefly be identified and explored. Again, it is important the social worker fully evaluate and assess the client and family need in order to identify appropriate and least intensive treatment.

Family Behavioral Therapy

Family Behavioral Therapy (FBT) aims to treat youth and adults with substance use disorders and has gained empirical support over the past two decades. From the FBT perspective, substance use has come to represent both positive and negative reinforcers; being positively reinforced by physiological pleasures and relationships with other users, yet negatively reinforced by hangovers, arguments, and becoming disconnected from healthy support systems ( Donohue, Allen, & LaPota, 2009 ). Treatment is typically 6 months in length and occurs over a period of 15, 90-minutesessions. Central to FBT is the involvement of one or more family members, usually one or both parents. FBT utilizes multiple treatment intervention approaches: skill-based interventions that reinforce healthy behaviors, behavioral contracting, skills-training techniques targeted at decreasing impulses and urges to use substances, communication skills to assist in development of healthy relationships and avoidance of substance-abusing peers, and training associated with academic achievement ( NREPP, 2006 ). FBT is now listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP;  www.nrepp.samhsa.gov ).

Brief Strategic Family Therapy

Brief Strategic Family Therapy (BSFT) was developed in response to an increase in Hispanic adolescent drug use in the 1970’s ( Robbins et al., 2003 ;  Szapocznik, Hervis, & Schwartz, 2003 ), and has since become the primary model used to work with Hispanic families with behavior problem youth, including alcohol and other drugs (AOD). BSFT is based on three central constructs: systems, structure/patterns, and strategy. BSFT proponents believe that a family is a system comprised of individuals whose behaviors affect other family members. Structure and 47 patterns refer to the set of repetitive patterns of interactions that are idiosyncratic to a family. A maladaptive family structure contributes to behavior problems such as conduct disorder and AOD use. Strategy is the third central construct on which BSFT is based. Therapists that adhere to BSFT use family interventions that are practical, problem-focused, and deliberate ( Robbins et al., 2003 ). Therapy sessions, which involve the entire family, are generally once a week for 8 to 12 weeks and last between an hour and an hour and a half.

Robbins et al. (2003)  highlight three key assumptions to BSFT: (1) changing the family is the most effective way of changing an individual;(2) changing an individual and then returning him or her to a detrimental or negative environment does not allow the individual changes to remain in place; and (3) changes in one central or powerful individual can result in changes in the rest of his or her family. For additional information on BSFT see  www.ncjrs.gov .

Multisystemic Therapy

Multisystemic therapy (MST) was developed by Scott Henggeler and his colleagues ( Henggeler & Borduin, 1990 ;  Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998 ) at the Family Services Research Center, Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina in Charleston. MST is a family- and community-based treatment approach that is theoretically grounded in a social-ecological framework ( Bronfenbrenner, 1979 ) and family systems approach ( Haley, 1976 ;  Minuchin, 1974 ). This overview of MST is included here because the “MST is consistent with the family preservation model of service delivery” ( Schoenwald, Borduin, & Henggeler, 1998 , p. 488).

MST is being used across the United States in communities implementing a “wraparound” approach to service delivery, where the focus is on delivering client-centered, culturally competent services in the least restrictive but clinically appropriate environment (cf.  Schoenwald et al., 1998 ). The social-ecological model views human development as a reciprocal interchange between the client and “nested concentric structures” that mutually influence each other ( Henggeler, 1999 ). Furthermore, the ecological perspective asserts that one’s behavior is determined by multiple forces (e.g., family, school, work, peers) and is supported by causal modeling of delinquency and substance abuse ( Henggeler, 1997 ).

There are nine guiding principles that the MST practitioner should follow ( Schoenwald, Bordulin & Henggeler, 1998 ):

1. The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.

2. Therapeutic contacts should emphasize the positive and should use systemic strengths as levers of change.

3. Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members.

4. Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.

5. Interventions should target sequences of behavior within and between multiple systems.

6. Interventions should be developmentally appropriate and fit the developmental needs of the youth.

7. Interventions should be designed to require daily or weekly effort by family members.

8. Intervention efficacy is evaluated continuously from multiple perspectives.

9. Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change. (pp. 488–489)

These nine principles can be used to guide practice with substance-abusing youth.

Henggeler (1999)  has summarized the MST model of service delivery. The MST practitioner typically carries a low caseload of five to six families, which allows for the delivery of more intensive services (2 to 15 hours per week) than traditional approaches (normally 1 hour per week). The practitioner is available to the client system 24 hours a day, 7 days a week. Services are delivered in the client’s natural environment, such as his or her home or a neighborhood center. Treatment is typically time limited, lasting 4 to6 months. Given the level of commitment required of the practitioner, MST may be difficult to implement for some agencies. For a detailed exposition on implementing MST with high-risk youth, see  Henggeler and Borduin (1990) .

According to  Henggeler (1999) , MST utilizes treatment approaches that are pragmatic, problem focused, and have some empirical support, including but not limited to strategic family therapy ( Haley, 1976 ), structural family therapy ( Minuchin, 1974 ), behavioral parent training ( Munger, 1993 ), and cognitive-behavior therapy ( Kendall & Braswell, 1993 ).  Brown, Borduin, and Henggeler (2001) , call MST “the only treatment for serious delinquent behavior that has demonstrated both short-term and long-term treatment effects in randomized, controlled clinical trials with violent and chronic juvenile offenders and their families from various cultural and ethnic backgrounds” (p. 458). Moreover, the potential cost savings of MST have been demonstrated with substance-abusing juvenile offenders (cf.  Schoenwald et al., 1996 ). For additional resources and information regarding MST, consult  www.mstservices.com .

Through the Campbell and Cochrane Collaborations, Dr. Julia Littell, a social work professor in Philadelphia, conducted her own systematic review on the effectiveness of MST ( Littell, 2005 ). In her review, Dr. Littell includes both published and unpublished studies, as is standard practice for reviews conducted through the Campbell and Cochrane Collaborations. In total, Dr. Littell and her colleagues identified 35 unique studies and included 8 in their review. Dr. Littell discovered an unpublished study by Dr. Alan Leschied, who conducted a trial of MST with 409 youth in Canada. She presented her findings at meeting of the Campbell Collaboration, suggesting that MST may not be as effective as has been previously thought. A recent development in this line of inquiry appeared in the form of letters to the editor of Children and Youth Social Services, both from Dr. Scott Henggeler, the developer of MST, and his colleagues (Henggeler, Schoenwald, Borduin, & Swenson, 2006) and from Littell (2006). There continues to be much debate surrounding the effectiveness of MST following Dr. Littell’s review of the research; yet, we have included it here for several reasons. MST is still quite popular. It is used in many states and communities, and MST remains one of the National Institute on Drug Abuse’s recommended scientifically based approaches to drug abuse treatment. Only additional research will shed additional light on its effectiveness.

Structural-Strategic Family Therapy

Structural family therapy was developed at the Philadelphia Child Guidance Clinic by Salvador Minuchin and his associates ( Minuchin, 1974 ;  Minuchin & Fishman, 1981 ), including Jay Haley, whose work with Cloe Madanes subsequently led to the strategic approach ( Haley, 1976 ). Like other family therapists, structural-strategic therapists view the interactive behaviors of family members as forms of communication. The therapy is goal oriented and short term, typically lasting 10 to20 sessions over a period of four to six months ( Todd & Selekman, 1994 ). Therapeutic goals are consistently related to drug abuse, but they also should relate to broader issues, such as family roles and interaction patterns. A basic assumption of this approach is that problems are maintained by dysfunctional family structures and rules. Accordingly, a major goal of family therapy is to alter the family structure that maintains the substance-abusing behavior. For example, with substance-abusing youth, a goal might be to restructure the family system so that the parents are in charge. Strategic techniques tend to bevery direct.

When working with youth, this model avoids the use of labels such as “addict” and “alcoholic.” These labels can actually be harmful to a youth, particularly early in treatment, before the practitioner knows how responsive the youth may be to treatment ( Todd & Selekman, 1994 ). Moreover, studies have demonstrated that youth do not accept such labels because of their developmental stage and what they value ( Glassner & Loughlin, 1987 ). In implementing a structural-strategic model with substance-abusing adolescents,  Todd and Selekman (1994)  do not routinely refer an adolescent to a twelve-step recovery group when they believe that applying an “addict” or “alcoholic” label may be harmful. However, they do recommend making such a referral when an adolescent needs the support of such a group or when he or she is immersed in the drug culture.

Goal setting is a critical task early on in family treatment and must be done with each family member. Each family member should be allowed to state what he or she would like to get out of family therapy. The practitioner’s job is to help the family see how their stated goals overlap and to point out common threads, even when members’ stated goals differ. It is also the practitioner’s job to help the family establish goals in two major areas: elimination of substance use and improved interpersonal relationships, with a clear relationship between the two ( Todd & Selekman, 1994 ).

Additionally, should the youth relapse, a crisis will most likely follow. It often takes a crisis for people to change, so the practitioner may want years and had two children: Steven, to mobilize the family to meet the challenges associated with the relapse. It is important to capitalize on the family’s strengths. If the family has made considerable progress and a member relapses, then the practitioner should point out that the family unit has demonstrated their ability to cope with tough problems in the past and instill a sense of hope that they will overcome this obstacle as well. In other words, it may be more therapeutic to view a relapse that occurs later on in treatment as a temporary “slip,” rather than as a permanent reversion to drug use ( Todd & Selekman, 1994 ). Readers interested in learning more about this approach to working with families are referred to the following excellent sources:  Haley (1976) ;  Minuchin (1974) ;  Minuchin and Fishman (1981) ; and  Todd and Selekman (1991) .

The efficacy of structural family therapy with adolescent drug abusers has been demonstrated in the literature (cf.  Fishman, Stanton, & Rosman, 1991 ;  Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1983 ,  1986 ). For information on the effectiveness of other family-based interventions with adolescents, see  Alexander and Parsons (1973) ;  Aponte and VanDeusen (1981) ;  Gutstein, Rudd, Graham, and Rayha (1988) ;  Klein, Alexander, and Parsons (1976) ;  Szapocznik et al. (1989) ; and  Waldron et al. (2001) .

Multifamily Therapy Groups

Multifamily therapy groups (MFTGs) are also being used as a component of treatment approaches for youth with substance abuse problems. A multifamily group usually consists of several youths and their family members, including parents, legal guardians, and siblings. In other words, it is a group consisting of several families, with each family viewed as a client system. An acceptable size for such a group is anywhere from 3 to 7 families. The use of two group leaders is recommended due to the size of most MFTGs. A group session may last approximately 1½ to 2 hours.

Techniques of structural-strategic family therapy, discussed earlier, are also often used. Therefore, the facilitator must possess a working understanding of group work and family therapy and be able to integrate the two in practice. By focusing on the interactions between members and families that take place in the here-and-now of the group experience, group members learn how they impact or are perceived by others, get feedback about their behavior, learn from one another, and practice new skills ( Springer & Orsbon, 2002 ). This is accomplished in the context of a supportive helping system. Multifamily therapy groups have been used successfully with substance-abusing adolescents and their families (cf.  Malekoff, 1997 ;  Polcin, 1992 ;  Singh, 1982 ;  Springer & Orsbon, 2002 ).

Residential Treatment/Therapeutic Communities

An alternative to inpatient hospital treatment is longer-term residential treatment. Therapeutic communities (TCs) are one example of long-term residential care. Once admitted to such a facility, the adolescent is encouraged to form close emotional ties with other clients. When successful, the adolescent will perceive himself or herself as part of a group of peers who act as a support network ( Obermeier & Henry, 1988-1989 ). If a third-party payer is involved, a dual diagnosis of the youth is generally required to warrant payment for such treatment.

There is no evidence to suggest that inpatient treatment is any more effective with most youth than outpatient treatment ( Gerstein & Harwood, 1990 ;  McBride et al., 1999 ;  McLellan et al., 1982 ). However, for many parents who avail themselves of extended inpatient treatment for their children, the treatment period gives them a respite. Critics of this approach suggest that for improvements to be maintained, the youth should be treated while residing in his or her home setting (as is done with MST, described earlier). Changes that occur within a residential setting frequently occur within a vacuum, and the typical frustrations and challenges that might encourage alcohol and drug use and abuse are absent in such a setting. Thus, the improvements seen in the hospital do not necessarily extend to the home setting ( Joaning, Gawinski, Morris, & Quinn, 1986 ).  Friedman and Utada (1983)  found that outpatient settings devoted more staff time to individual and family counseling than residential programs, which had a heavier emphasis on art therapy, group counseling, vocational training, and medical services.

There is little doubt that extended residential communities are necessary for seriously disturbed youth. When a youth chronically endangers himself or herself with drug and/or alcohol use, extended residential treatment may be the desired alternative so his or her behavior can be monitored 24 hours a day ( Downey, 1990–1991 ).

Research on the effectiveness of TCs for an adolescent reveals that the length of stay in treatment is the largest and most consistent predictor of positive outcomes ( Catalano, Hawkins, Wells, Miller, & Brewer, 1990–91 ;  De Leon, 1988 ). Positive outcomes—such as engaging in no criminal activity, using no alcohol or drugs, and having employment—are all associated with longer stays in treatment ( McBride et al., 1999 ). “Therefore, while juvenile TCs advocate comparatively shorter treatment times than adult TCs, it is essential that programs allow adequate time for treatment effectiveness” (p. 48).

Positive Peer Culture

In the case of work with adolescent substance abusers in residential settings, such as therapeutic communities, forms of Positive Peer Culture (PPC) are often used to facilitate group treatment. Positive Peer Culture, developed by Harry Vorrath, was heavily influenced by a peer-oriented treatment model called Guided Group Interaction (GGI).  Vorrath and Brendtro (1985)  have called PPC “a total system for building positive youth subcultures” (p. xx).

PPC is a holistic approach to working with youth in a therapeutic setting. It is not simply a set of techniques but rather attempts to change the culture in the therapeutic setting. “PPC is designed to ‘turn around’ a negative youth subculture and mobilize the power of the peer group in a productive manner. . . .  In contrast to traditional treatment approaches, PPC does not ask whether a person wants to receive help but whether he is willing to give help” ( Vorrath & Brendtro, 1985 , p. xxi). Proponents of PPC view troubled youth not as rebellious or “bad seeds” but rather as individuals that, with nurturing, can have much to contribute. The list below synthesizes and highlights some key aspects and assumptions of the PPC approach discussed by  Vorrath and Brendtro (1985) :

· PPC does not seek to enforce a set of specific rules but to teach basic values.

· The peer group has the strongest influence over the values, attitudes, and behavior of youth.

· Adults have much to offer youth, but should not attempt to control or surrender to them.

· Youth feel positive about themselves when two conditions exist: the youth feel accepted by others, and the youth feel deserving of this acceptance.

· Youth are experts on their own lives.

· Youth are resilient.

· Youth possess strengths that should be recognized by practitioners and tapped throughout the treatment process (i.e., a strength perspective). When these strengths are tapped, youth are better able to help one another.

· PPC focuses on the “here-and-now” of what is happening.

· PPC views problems as opportunities rather than as trouble.

· Youth must accept responsibility for their behavior and be held accountable.

· Both youth and adults must care for and help one another.

Simply stated, the essence of PPC is captured in the following statement: “If there were one rule, it would be that people must care for one another” ( Vorrath & Brendtro, 1985 , p. xxi).

Vorrath and Brendtro (1985)  do not recommend co-educational groups because they present barriers to relaxed and open interaction. This is because male and female adolescents often engage in courtship behavior that masks honest communication. The authors recommend a group size of nine youths.

PPC has been used effectively with adolescents presenting with a variety of problems, including but not limited to increased feelings of self-worth and reduced delinquent values and attitudes ( Michigan Department of Social Services, 1983 ), a reduction in asocial behavior ( McKinney, Miller, Beier, & Bohannon, 1978 ), and runaway and physically aggressive behavior in female delinquents ( Quigley & Steiner, 1996 ). For more information about PPC, see  Vorrath and Brendtro’s (1985)  classic text on the subject.

Case Example

Consider the following case example, which illustrates some of the material discussed thus far. The youth presented is similar to many who participated in this particular treatment program, which was an intensive outpatient program (IOP) that was part of a larger treatment network for dually diagnosed adolescents.

Mr. and Mrs. Williams had been married for20 years and had two children: Steven, 16 years, and Sally, 13 years. The Williams’ initially sought treatment for Steven, who had been clinically depressed for about two months (meeting diagnostic criteria for major depressive disorder). Steven also used alcohol (three to four nights a week), marijuana (mostly on weekends), and ecstasy when he went to clubs (about every other weekend). He had also been exhibiting angry behavior in school and at home. He recently got into a fight at school that led to a referral to an alternative learning center (ALC) located at a separate campus, which is used in lieu of expulsion for serious infractions of school rules.

As part of Steven’s treatment through the IOP, he attended interactional therapy groups and psychoeducational groups, as well as individual therapy, three days a week after attending the ALC. Multifamily therapy groups and individual family sessions were each held weekly. Even though Steven’s family was involved in his treatment, as should be the case with a substance-abusing youth, the focus here is primarily on Steven. (For a case example that focuses on the family in treatment, the reader is referred to  Chapter 10 .)

During an initial individual session, Steven admitted that he was afraid that his alcohol and drug use were interfering with his functioning. He cited a couple of recent blackouts, episodes of fighting, and problems concentrating on schoolwork. After explaining some of the potential health problems that can be caused by excessive drinking and drug use (marijuana and ecstasy), the therapist requested that Steven undergo diagnostic tests to ascertain the level of impairment, especially to his liver, cardiovascular system, and nervous system. The therapist believed that it was ethically necessary to rule out organic difficulties by qualified medical professionals before beginning substance abuse or mental health treatment. Doing so was crucial to understanding which erratic behaviors, if any, were influenced by somatic difficulties. Steven was medically cleared.

Providing adolescent substance abusers one-on-one time with the therapist early on in treatment is helpful in establishing rapport ( Todd & Selekman, 1994 ). By joining with Steven, the therapist did not lose him when it came time to empower his parents to set and enforce limits. Empathy and humor proved useful in helping the therapist engage Steven.

Steven’s depression was targeted with a combination of cognitive-behavioral therapy and medication management with Zoloft. The psychoeducational groups proved particularly useful in getting Steven to dispel some of the common myths that surround ecstasy use among club users. A structural-strategic approach to family therapy, as discussed earlier in this chapter, was used to guide the individual family therapy sessions.

At school, Steven’s behavior improved markedly and his grades were improving as well. Steven received additional counseling from a school social worker at the ALC, who was knowledgeable about teenage drug abuse. The focus of those sessions was to reconsider his peer group in an attempt to prepare him for return to his regular school. Although Steven received support from some of his friends, other friends heavily used alcohol and other drugs. The latter group of friends were ambivalent about Steven’s decision to abstain from alcohol use, although they did not explicitly criticize his choice. However, the school social worker was worried that substance-abusing friends were not diligent about schoolwork and attending class. In addition, these friends were often involved in verbal and physical fights with other students. Over time, Steven established new friendships with peers that were supportive of his drug-free lifestyle, but this initially required consistent prompting by the social worker and structured monitoring by his parents. As Steven earned back his parents’ trust, he was gradually given additional privileges at home.

Although the groups ended, maintenance family therapy sessions continued once a month. Steven relapsed once during the course of treatment. This was normalized for both Steven and his family, as for many substance-abusing adolescents in treatment relapse. The social worker helped the Williams family realize the progress that they had made and how their strengths could be used to resolve the crisis.

Recall from earlier in this chapter that not all adolescents respond equally to twelve-step recovery groups and that in implementing a structural-strategic model with substance-abusing adolescents,  Todd and Selekman (1994)  do not recommend routinely referring adolescents to twelve-step recovery groups when they believe that applying an “addict” or “alcoholic” label may be harmful. In keeping with this philosophy, Steven was not referred to AA or NA. He continued meeting informally with the school social worker, who proved invaluable in providing information and support on a sustained basis.

Chapter 10 Family Systems and Chemical Dependency

Catherine A. Hawkins

Texas State University-San Marcos

Raymond C. Hawkins, II

Fielding Graduate University

Previous chapters indicate that alcoholism and other drug addictions frequently impair an individual’s physical, psychological, and social functioning. There is also recognition that alcoholism and other drug addictions adversely affect the individual’s marital and family relationships. In a Gallup poll, more than a third of respondents reported that drinking had caused problems in their family ( Newport, 1999 ). Another Gallup poll based on interviews with 902 U.S. adults with an immediate family member with a drug or alcohol addiction reported that the family member’s addiction had a negative effect on their own mental health (70 percent of respondents) and their relationship with other family members (51 percent) ( Saad, 2006 ). These negative effects are far-reaching, given the prevalence of parental alcoholism. “It can conservatively be estimated that approximately 1 in every 4(28.6 percent) children in the United States is exposed to alcohol abuse or dependence in the family” ( Grant, 2000 , p. 114).

Defining alcoholism at the family level lacks specificity, despite its intuitive appeal. Many terms in the literature attempt to capture this phenomenon, such as family disease, alcoholic family, addicted or chemically dependent family, alcohol impaired family, or family with an alcoholic member. An understanding of the family dynamics associated with alcoholism or other drug addiction must entail descriptions of interactive processes that occur throughout the life cycle of the family. In addition, family is a term that is no longer clearly defined in society. The material presented here applies to all forms of families, including nuclear, extended, single-parent, communal, kinship, and gay/lesbian.

This chapter examines some of the more noteworthy efforts to specify the etiology and treatment of the family processes associated with chemical dependency. The term alcoholism will be used, although theoretically, much of the scholarly literature can be reasonably generalized to other drug addiction. The literature on a family perspective of chemical dependency, including the theory, research, and treatment of alcoholism and other drug addiction in families, is discussed. Three dominant theoretical approaches—behavioral, stress coping, and family systems—are presented. The constructs of codependency, children of alcoholics, and adult children of alcoholics are explored as they relate to family dynamics. The ways in which theory shapes practice with chemically dependent family systems are addressed along with more specific treatment information. Finally, a case example is presented that illustrates some of the main concepts discussed in this chapter.

A Family Perspective in Theory, Research, and Treatment

During the early decades of the twentieth century, a scientific tradition emerged in the social sciences. The study of alcoholism, however, was restrained by the moral overtones attached to the problem, which led to the belief that alcoholism was not amenable to scientific inquiry. The growing Temperance Movement culminated in the Prohibition amendment in 1919. Attempts at treatment of alcoholism (which were almost exclusively directed at men) consisted largely of removing the individual to a residential program for detoxification and some therapy, known euphemistically as “the cure.” In Alcoholics Anonymous, Bill W., a founder of Alcoholics Anonymous (AA), describes his “rehabilitation” as belladonna treatment, hydrotherapy, and mild exercise ( AA, 1939 ).

In the 1930s, the disease or biological model of alcoholism began to gain acceptance. AA, founded in 1935, embraced this model. Although AA was originally oriented toward men, wives would hold meetings modeled after AA to discuss the effects of alcoholism on their lives. (Lois W., Bill W.’s wife, is credited with organizing the first meeting.) At this same time, psychoanalysis was growing in popularity, and it explained alcoholism in terms of psychopathology. Both these models were limited to an examination of the etiology of alcoholism in the individual. Psychoanalysts acknowledged the impact of family dynamics on psychopathology, and they had some interest in the family aspects of alcoholism, but they looked at psychopathology in terms of each individual partner rather than their interaction ( Lewis, 1937 ). Psychoanalytic practice wisdom prohibited the involvement of family members in therapy with the alcoholic, as this was believed to contaminate the therapeutic transference. Another development of the 1930s was the emergence of the fields of marital therapy and child guidance, with their focus on interpersonal relationships. However, early practitioners used a collaborative approach in which separate therapists would meet with family members, and then the therapists would consult with each other on their treatment session ( Goldenberg & Goldenberg, 2008 ).

Theory and research on alcoholism grew through the 1940s and 1950s but continued to be limited to a study of its physiological and emotional effects on the individual (predominantly middle-aged Anglo males), such as the seminal work by Jellinek (1960). Even the conceptualizations of alcoholism in the marital dyad maintained an individual focus ( Billings, Kessler, Gomberg, & Weiner, 1979 ;  Finney, Moos, Cronkite, & Gamble, 1983 ). For example, the distressed personality model, rooted in psychoanalysis, held that underlying psychopathology in the wife led to the development and maintenance of a drinking problem in the husband ( Futterman, 1953 ;  Kalashian, 1959 ;  Price, 1945 ). Alternatively, the stress personality model, which applied to both genders, viewed personality disturbance in the spouse as resulting from the chronic stress in the home generated by the alcoholic ( Jackson, 1954 ).

In the 1940s, the concurrent approach to marital and family therapy began to emerge. In this model, one counselor would work with a couple but would meet with them separately ( Goldenberg & Goldenberg, 2008 ). One of the first attempts to include families in treatment involved concurrent group therapy for alcoholics and their wives ( Ewing, Long, & Wenzel, 1961 ;  Gliedman, Rosenthal, Frank, & Nash, 1956 ). These early programs demonstrated that involving spouses increased the completion rate of treatment and expanded the criteria of successful outcome to include both partners’ psychosocial functioning as well as abstinence by the alcoholic ( Steinglass, Bennett, Wolin, & Reiss, 1987 ). By 1948, the support groups organized by the wives of AA members had become a formal network called Al-Anon Family Groups, targeting spouses of both genders. (For a description of the Al-Anon program, see  Albon [1974] ,  Kurtz [1994] , and  Keinz, Schwartz, Trench, & Houlihan [1995] .) In 1957, Alateen was formed for teenage children of alcoholics, and later, Alatot groups were developed for younger children. By the late 1950s, the conjoint approach to marital and family therapy was introduced, in which one counselor would meet with couples and families as a unit ( Goldenberg & Goldenberg, 2008 ).

In the 1960s, as social science moved away from a strictly individual perspective and began to consider the influences of the environment, a third model for conceptualizing alcoholism in the marital dyad emerged. The psychosocial model integrated the distressed personality and stress personality models ( Bailey, 1961 ). It focused on the consequences of the alcoholic’s drinking behavior and the spouse’s coping style on both the marital partners. Through the 1960s, the rise of systems theory and behavioral theory led to a broader perspective that focused on the interactive, reciprocal nature of family processes. Although conjoint family therapy developed during this time, family treatment for alcoholism continued to consist of a concurrent program for nonalcoholic spouses (i.e., wives). This was attributed to the general ignorance of alcoholism by family therapists, who often failed to identify this problem or considered it secondary to other problems. When alcoholism was recognized as a problem, family therapists frequently referred these families to alcoholism treatment programs, where alcoholism was viewed as an individual disease ( Steinglass, 1987 ). Alcoholism counselors reportedly avoided a family perspective due to lack of training or a belief that it was incompatible with the disease model.

This situation gradually changed during the 1970s and 1980s. Today, some type of family involvement is often included in most alcoholism treatment programs. There is considerable variation across programs, however, ranging from “family night” to full-fledged family therapy. At the same time, both the self-help and clinical movements recognize that family members have problems in their own right due to the dynamics of alcoholism. This led to such concepts as codependency, children of alcoholics, and adult children of alcoholics. According to  Seilhamer and Jacob (1990) , Western cultures have long recognized the detrimental impact of parental alcoholism on children. However, there was little interest in these children until the first publications identifying the clinical implications of being raised by an alcoholic parent began to appear ( Ackerman, 1986 ;  Bosma, 1972 ;  Cork, 1969 ;  Slobada, 1974 ). This was soon followed by an awareness of the impact of parental alcoholism on the adult functioning of offspring (the Adult Children of Alcoholics or ACOA movement). Being the child of an ACOA (i.e., grandchild of an alcoholic), whether the parent is alcoholic or not, also has a potentially negative impact, since alcoholism can affect families for several generations ( Smith, 1988 ;  Stein, Newcomb, & Bentler, 1993 ). As a result, self-help and advocacy groups (such as the National Association for Children of Alcoholics) have emerged. ACOA support groups originally began in the 1970s under the auspices of Al-Anon. Over the next few years, independent ACOA groups developed, and Co-dependents Anonymous (CODA) groups were also established.

Since the 1990s, with the advent of behavioral managed care, cost containment has affected substance abuse treatment. For example,  Platt, Widman, Lidz, Rubenstein, and Thompson (1998)  conducted a review of the research literature on support services, including family therapy, as an adjunct to substance abuse treatment. The authors found that despite clear evidence of the need for support services to increase treatment effectiveness, clients often do not receive these services through their health care provider or get adequate referrals to other agencies.  Steinglass (2006)  and  Corless, Mirza, and Steinglass (2009)  critique the impact of managed behavioral health care on systemic medicine and call for the family therapy field to more directly address substance misuse.

The scholarly literature on family treatment includes studies in which the alcoholic is typically a parent, spouse, or child. As described elsewhere in this book, there is a long-standing tradition of using a family perspective with adolescents, although empirical studies in which the chemically dependent person is a woman or a member of a racial or ethnic minority group are limited. There is an emerging literature on family treatment in which the alcoholic family member is elderly, mentally ill, or gay/lesbian.

Theories on Alcoholism and the Family

Chapter 2  covered many theories regarding the etiology and treatment of alcoholism. At one extreme is a strict medical model, also known as the disease model, focused on individual biological factors with virtually no consideration of familial, social, or psychological variables. At the other extreme is a strict family systems model, focused on the family as a unit, with little consideration of the individual as distinct from the family. In the middle are theories that address, to varying degrees, both the individual and the familial aspects of dysfunction, such as behavioral and stress coping models. The difference between these various theories can be quite confusing, even to a person familiar with the chemical dependency field. This section will discuss the three predominant models that address alcoholism at the family level: behavioral, stress coping, and family systems.

Family systems theory evolved in the 1950s as an outgrowth of general systems theory, which emerged in biology in the 1940s. This theory represented an epistemological shift from a reductionist, linear (cause and effect) way of thinking to one of circular causality, process orientation, and the interrelatedness of parts. The crux of systems theory, as applied to people, holds that addiction, like any other human behavior, exists in a larger context. However, the family is viewed not merely as the context for an individual’s behavior but also as an entity unto itself. Rather than expressing individual pathology, the presence of problematic behavior (such as alcoholism) in a family member is considered a symptom of underlying dysfunction in the system. The alcoholic is referred to as the identified patientto indicate that it is the system itself that is dysfunctional. Rather than identifying the effects of alcoholism on the individual members of the family, a family systems approach focuses on the individuals and the interactions among them. The structure and dynamics of the family are assessed, and intervention is planned, through applying systems concepts such as homeostasis, boundaries, triangles, and feedback. (See any basic family therapy text, such as  Nichols [2009] , for a discussion of these concepts.)

The behavioral and stress-coping models first developed as theories of individual behavior but now incorporate a systems perspective. They recognize that relationships among the family members are interrelated and reciprocal and that the individual both influences and is influenced by other family members. In turn, the family exists as part of the larger social system that affects both individual and family functioning. However, these models differ from family systems theory in that the family is generally seen more as a context for individual behavior than as an entity unto itself. Although all three theories share a social systems orientation, the term family systems is used here specifically in reference to that particular theoretical orientation, even though the term is often used more broadly in the literature. Further, it should be noted that most family systems intervention models actually treat the family as a closed system, rather than focusing on the family’s interactions with the larger environment.

Family Systems Theory of Alcoholism and the Family

This section focuses on family systems theory, especially three significant areas of family systems literature on alcoholism: rituals and routines, shame, and rules and roles. A discussion of the behavioral and stress-coping models is presented later in the section on assessment and treatment.

Two criticisms of family systems theory should be noted. First, some critics claim that it is largely descriptive, non-scientific, imprecise, and virtually untestable. However, its defenders consider such criticisms to be irrelevant, since the main value of systems theory is not as a traditional scientific model but as a fundamentally different approach to the conceptualization of clinical problems and therapeutic interventions. Second, feminist theory contends that there is a gender bias in family systems theory.  Goldner (1985)  argues that the central tenet of context—defined as a boundary that can be drawn around a family, thereby making it a distinct entity—disregards the social forces that influence the family. Another central tenet, circularity, assumes an equal distribution of power when, in fact, women are often regarded as subordinate to men within families just as they are within the larger society. Goldner warns that ignoring the impact of the social context can lead to theorists and practitioners “blaming the victim” and “rationalizing the status quo” rather than challenging oppressive sex-role arrangements in family life.

Rituals and Routines

Steinglass and colleagues (1987)  distinguish between an alcoholic family, which is tantamount to an alcoholic system, and a “family with an alcoholic member.” This distinction is made by applying three core concepts of family systems theory: (1) organization, (2) morphostasis or internal regulation, and (3) morphogenesis or controlled growth. The authors cite numerous studies that demonstrate the significance of ritual invasion in the development and maintenance of alcoholism in a family.

In the alcoholic family, chronic alcoholism has become its central, organizing theme. According to Steinglass et al., in these families alcoholism is no longer just operating at the individual level, it has become incorporated into virtually every aspect of the family. The erratic and unpredictable behavior of the alcoholic, over time, often elicits a characteristic response from other family members. Their behavior becomes impaired and contributes to the perpetuation of the drinking behavior, thus establishing a circular, reciprocal pattern within the family. The functioning of a family organized around alcoholism can be further understood by applying the principles of family systems theory, such as wholeness, boundaries, and hierarchies.

This organization occurs through a process in which the family’s regulatory behaviors (morphostasis) are altered to make them more compatible with avoiding the stress and conflict associated with alcoholism. The family accommodates to alcohol-related behaviors in an effort to achieve short-term stability (the process of morphostasis is also called homeostasis). However, this increases the likelihood that the drinking will continue, because the system has (inadvertently) been organized to maintain it. Family rituals offer the clearest opportunity to investigate this developmental process since they are considered to be the most meaningful shared activity.

Rituals, encompassing cultural traditions, family celebrations, and daily routines are symbolic events repeated in a systematic fashion over time that convey a sense of belonging among family members. Cultural traditions include religious and secular events that are generally observed by the larger society, such as Christmas, Thanksgiving, or Independence Day. Family celebrations, such as birthdays, graduations, weddings, vacations, and reunions, are special events that, although perhaps shared with the larger society, are practiced in unique ways by each family. Daily routines are the most distinctive form of activity and vary widely across families. Routines reveal how the family relates in terms of time and space, such as dinnertime, bedtime, and leisure time. “The one construct that more clearly encapsulates the notion of the Alcoholic Family (a family organized around alcoholism) (is the) invasion of family regulatory behaviors by alcoholism” (p.  72 ). For example, the family may stop having meals together if the mother drinks in the evening and does not prepare them.

The family’s long-term growth and development (morphogenesis) entails three major tasks that determine the family’s identity: defining boundaries, establishing a family theme, and choosing shared values. Although greatly simplified in the present discussion, families accomplish these tasks as they move through a common developmental pathway encompassing early, middle, and late phases. During each developmental phase, the alcoholic family makes crucial, usually unconscious, decisions to either challenge or accommodate the drinking behavior of a family member and thus shapes family identity. In the early phase, the family initiates its identity. A key variable is how closely a couple links with their respective families of origin (which may also be alcoholic), since this will influence how the family responds to emerging drinking behavior. If the drinking behavior is not resolved, the middle phase for alcoholic families is characterized by maintaining this established identity. For alcoholic families, this means organizing around alcohol-related behaviors (i.e., invasion of rituals by alcoholism). In the later phase, the family consolidates and defends its alcoholic identity and, if the drinking is not successfully confronted, transmits this identity to future generations. Thus, according to this model, the etiology of an alcoholic family is rooted in the sacrifice of morphogenesis (long-term growth) for morphostasis (short-term stability).

Shame

Another construct associated with alcoholic systems (which is clinically derived but lacks adequate empirical validation) is shame. Although normative shame is necessary for an individual to be socially functional, shame-bound families are thought to engage in pathological patterns of communication and interaction that instill a sense of toxic shame in their offspring. There is considerable theoretical literature on the relationship between shame and chemical dependency at both the individual and family level ( Fossom & Mason, 1986 ;  Hawkins, 1996c ;  Kaufman, 1985a ,  1985b ;  Potter-Efron, 1989 ;  Potter-Efron & Potter-Efron, 1988 ).

Fossom and Mason define shame as “an inner sense of being completely diminished or insufficient as a person . . . the ongoing premise that one is fundamentally bad, inadequate, defective, unworthy, or not fully valid as a human being” (p.  5 ). Shame differs from guilt in that the latter comprises a painful feeling of regret for one’s actions while the former is an acutely painful feeling about one’s self as a person. Guilt offers the opportunity to reaffirm personal values, repair damage, and grow from the experience. Shame, however, is more likely to foreclose the possibility of growth, since it reasserts one’s self-identity as unworthy. Although shame is experienced as an intra-psychic process, its development occurs primarily through the interactions of the family. A shame-bound family operates according to

a set of rules and injunctions demanding control, perfectionism, blame, and denial. The pattern inhibits or defeats the development of authentic intimate relationships, promotes secrets and vague personal boundaries, unconsciously instills shame in the family members, as well as chaos in their lives, and binds them to perpetuate the shame in themselves and their kin. It does so regardless of the good intentions, wishes, and love which may also be a part of the system (p.  8 ).

Shame-bound systems can be addictive, compulsive, abusive, phobic, or exhibit some combination of these behaviors. Alcoholic families are susceptible to shame in at least two ways. First, members often construct elaborate networks for hiding the alcoholism from each other and from the community. Second, alcoholism is frequently associated with emotional, physical, or sexual abuse. Such abuse, as well as neglect, is usually cloaked in secrecy. Secrets maintain the equilibrium of the system by inhibiting family members from changing their behaviors. Thus, secrets serve to perpetuate the addiction as well as the shame of the people involved.

Kaufman (1985b)  provides an explanation of how shame is transmitted from the family level to the individual. He theorizes that a single developmental process is involved that takes different pathways, either to a healthy self or to a shame-bound self. The outcome depends on the prevailing affect encountered by the child over time in his or her interactions with adults, primarily the parents. If the child’s basic needs (physical and emotional) are understood and acknowledged on a consistent and predictable basis over time, the child acquires an inner sense of trust and competence in his or her ability to get needs met. Ultimately, the child develops healthy self-esteem. However, if the parent fails to meet the child’s needs, the child attributes this as personal failure and feels deficient. If this pattern is repeated consistently over time, the normative experience of shame (which occurs when one’s needs are not met) evolves into the person’s inner experience or identity. A shame-bound self is governed by feelings of being diminished, lonely, worthless, and alienated. Given the complexity of any family system, a child is likely to experience a combination of enhancing and diminishing responses. Parents can replace a shame-inducing reaction in a child with an affirming one by accepting and explaining the parent’s own responsibility for the interaction. Thus, they free the child from the sense that he or she failed to elicit the needed response from the parent. Unfortunately, many alcoholic and codependent parents fail to take this corrective step.

Rules and Roles

Wegscheider (1981)  proposes a now classic model of family interactive processes. Both the alcoholic and other family members suffer from very low self-worth and reinforce it in each other. Thus, in a reciprocal process the family system does not encourage the health and wholeness of its members, nor do members encourage the health and wholeness of the family. All families, over time, establish rules and roles that determine values and goals, regulate power and authority, specify responses to change, and establish patterns of communication. These rules are seldom recognized consciously. “Alcoholic families are governed by rules that are inhuman, rigid, and designed to keep the system closed—unhealthy rules. They grow out of the alcoholic’s personal goals, which are to maintain his [sic] access to alcohol, avoid pain, protect his [sic] defenses, and finally deny that any of these goals exist” (p.  81 ). Wegscheider uses the analogy of a mobile, with family members suspended and held together by strings, which represent rules. Any action by the alcoholic reverberates throughout the system. The family’s reactions are intended to bring stability, but they actually produce a long-term maladaptive response.

Families also adjust to alcoholism through the process of establishing roles (i.e., outward behavior patterns). All families function through roles (such as parent, child, etc.), but roles in alcoholic families take on an added dimension. Although there is little empirical study on the subject, the model suggests that these roles are a way of maintaining stability, since families fail to confront the problem of alcoholism, which threatens the system. Thus, the family may preserve its identity, but at a high price of which it is seldom aware. Wegscheider describes six typical family roles: dependent (the alcoholic), enabler (the powerless spouse or partner), hero (the overachieving child), scapegoat (the delinquent child), lost child (the isolated child), and mascot (the immature child). This is only a schema; in small families, one person may assume more than one role and, in large families, one role may be played by several people. Further, roles may shift over time. Although these roles may appear in all families at some time, in alcoholic families, they are “more rigidly fixed and are played with greater intensity, compulsion, and delusion” (p.  85 ).

Codependency and Related Constructs

As discussed, alcoholism can be viewed at both the individual and familial level: An alcoholic suffers from personal impairment and contributes to the impairment of his or her family. Likewise, other family members can develop individual impairment and contribute to familial impairment. In turn, family dysfunction can exacerbate each individual family member’s problems. The impairment of family members (alcoholic or non-alcoholic) can encompass the three related constructs of codependency, children of alcoholics, and adult children of alcoholics.

Codependency

Several definitional issues need to be considered in a discussion of codependency. It is a ubiquitous concept in the fields of chemical dependency and mental health, yet there is no general agreement as to its meaning. The concept is clinically derived and has received limited empirical attention (e.g.,  Carruth & Mendenhall, 1989 ;  Cullen & Carr, 1999 ;  Wright & Wright, 1999 ). Despite its intuitive appeal, this ambiguity has led to much confusion and controversy in the appropriate use of this concept in assessment and treatment. In addition, although the term is used irrespective of gender, it is typically applied more to women ( Roth & Klein, 1990 ). This bias raises concerns about ignoring the oppression of women, discounting gender socialization, or pathologizing what may actually be highly desirable human traits ( Bepko, 1989 ;  Frank & Golden, 1992 ;  Jordan et al., 1991 ). (See  Chapter 15 .)

The concept originated when chemical dependency counselors first turned their attention to the spouse (i.e., wife) of the alcoholic. They used the term enabler since it was observed that the behavior of the spouse often served to support the alcoholic’s drinking. Another early term was co-alcoholic, which implied that the spouse also suffered from the disease through her relationship with the alcoholic. By the late 1970s, this term was replaced by codependent as the term chemically dependent became the more popular way to describe alcoholics and addicts.

Codependency is a useful framework for explaining some of the dysfunctional behaviors observed in the spouses of alcoholics. In their efforts to cope with the stressors brought on by their spouse’s drinking, they eventually become a part of the problem by enabling it to continue through their own dependence on the relationship with the alcoholic. This concept is also useful in treatment, since it provides a framework for spouses or other family members regarding their own recovery from the effects of alcoholism. The concept is often applied more broadly to describe individuals who engage in ongoing dysfunctional relationships, whether chemical dependency is present or not. Although these definitions imply that the individual is codependent in relationship to an alcoholic or other person, the individual is actually engaged in a disease process of dependency in his or her own right ( Schaef, 1986 ). Codependent characteristics are thought to emerge from childhood abuse experienced in one’s own family of origin. Hence, there is a clinically derived, theoretical relationship between the constructs of shame and codependency ( Hawkins, 1996b ,  1996c ,  1997 ).

The concept of codependency defies precision ( Morgan, 1991 ), and various authors have defined it with their own constellation of attitudes and behaviors. Two representative definitions that capture the gist of this concept are offered here.  Black (1990)  states that codependency is “characterized by the numbing of feelings, denial, low self-worth, and compulsive behavior. It manifests itself in relationships when you give another person power over your self-esteem” (p.  6 ).  Whitfield (1997)  defines it as “any suffering and/or dysfunction that is associated with or results from focusing on the needs and behavior of others . . . (so) that they neglect their true self—who they really are” (p.  19 ).

The prevailing developmental explanation is that codependency first occurs when children grow up in shaming family systems. They lose the ability to distinguish between their needs and the needs of others, and they do not develop a firm sense of self ( Kaufman, 1985b ). In adulthood, such individuals have difficulty managing stress, have problems engaging in mature relationships, are at increased risk for alcoholism, and are particularly vulnerable to becoming involved with an alcoholic or pre-alcoholic partner. Further, in the absence of some sort of treatment, these individuals will likely perpetuate this cycle with their own children. A term often used in the clinical literature to convey this concept is adult child, which implies that “within each of these adult-age individuals there is a child who has difficulty experiencing a healthy life until . . . recognition and healing of the past occur” ( Black, 1990 , p. 3). Interestingly, however, the literature on codependency and shame does not necessarily overlap. This is perhaps because codependency originated as a self-help movement, whereas conceptualizations of shame are more theoretically derived; however, knowledgeable practitioners link the two concepts.

Children of Alcoholics

A related issue to codependency is the concept of children of alcoholics (COAs). As stated previously, estimates indicate that at least one in four children under the age of 18 in the United States is exposed to alcoholism and/or alcohol abuse ( NIH, 1999 ). There is substantial clinical and empirical literature that indicates the detrimental effects of alcoholism on all family members, especially children, regardless of developmental stage (e.g.,  Copello et al., 2005 ;  Gruber & Taylor, 2006 ;  Peleg-Oren & Teichman, 2006 ). This more recent data confirms patterns identified over several decades. Being the child of an alcoholic puts an individual at greater risk for alcoholism than the child of a non-alcoholic ( Cadoret, 1990 ;  Russell, 1990 ;  Sher, Walitzer, Wood, & Brent, 1991 ). While there may be a genetic component to this risk ( Cadoret, 1990 ), studies indicate that family environment is also a critical contributing factor ( Cook & Goethe, 1990 ;  Heath & Stanton, 1998 ;  McGue, 1997 ;  Seilhamer & Jacob, 1990 ;  Copello et al., 2005 ). In addition to being at an elevated risk for alcoholism, children raised by alcoholic parents may be more vulnerable to psychosocial impairment than other children. COAs are “over-represented in the caseloads of medical, psychiatric, and child guidance clinics; in the juvenile justice system; and in cases of child abuse” (Seilhamer & Jacob, 1990, p. 169). Sher and colleagues (1991) found that in addition to being at higher risk for substance abuse problems, COAs showed more behavioral under control, neuroticism, and psychiatric distress as well as lower academic achievement and verbal ability than non-COAs.

Ongoing research is beginning to distinguish specific risk factors in families with a history of alcoholism that are associated with COA outcomes.  Windle (1997)  provides a dynamic diathesis-stress model of developmental psychopathology for COAs that shows how parental alcoholism may or may not lead to adult disorders. In this model, a family history of alcoholism influences other numerable variables—including biopsychosocial risk factors, situational stressors, and mental/physical health problems—that are reciprocally interactive within a broader sociocultural and historical context.  Hill and colleagues (1997)  point out the need to consider the interaction of parental alcoholism with other familial factors that can impair adult functioning, such as childhood socioeconomic stress. In a retrospective study using an adult sample,  Dube et al. (2001)  explored the relationship between parental alcohol abuse and child maltreatment. They found that COAs were 2 to 13 times more likely to experience adverse childhood events than non-COAs, and for those raised by both mothers and fathers who were alcoholic, the odds were even higher. Estimates of the relationship between parental substance use problems and child abuse and neglect differ based on the different ways these problems are measured ( Testa & Smith, 2009 ), but parents with substance use disorders involved in the child welfare system often have co-occurring problems such as mental illness, domestic violence, housing, etc., that must also be addressed if the home is to become suitable for the child ( Marsh, Ryan, Choi, & Testa, 2006 ).

Hussong et al. (2008)  recently reviewed three longitudinal studies of type and severity of negative life stressors. Their research involved 1,752 participants, 56 percent of whom were COAs, spanning the first 30 years of life. COAs were differentially more vulnerable to family-related negative stressors than non-COAs. Hussong et al. interpreted this result as indicating that COAs had experienced a disruption of the normal stable family routines that might predispose them to increased risk for psychopathology. This greater exposure to negative life stressors may be particularly detrimental to certain COAs who have temperaments characterized by impulsivity or sensation seeking ( Sher et al., 2010 ;  Dick et al., 2010 ).  Caspi et al., 2010  recently summarized the literature on this genetic sensitivity to certain environments. Possessing a specific gene variant alone (e.g., short 5-HTTLPR allele) does not simply determine increased likelihood for negative outcomes. Protective environments may ameliorate these vulnerabilities while the invasion of the protective family rituals/routines may exacerbate them.

Family-based preventative efforts are critical in reducing the incidence of child and adolescent substance abuse.  Lochman and van den Steenhoven (2002)  reviewed 30 years of research and conclude that behaviorally-oriented parenting programs directed at particular risk factors can have a significant impact on improving parental disciplinary efforts and children’s behavior. The literature suggests that development of alcohol and other substance misuse by COAs and adolescents in general may be prevented by a particular form of extended protective environment: parental monitoring or supervision. Several recent empirical studies ( Fromme, 2006 ;  Fromme, Corbin, & Kruse, 2008 ;  Wetherill & Fromme, 2007 ;  Wetherill, Neal, & Fromme, 2010 ) and reviews ( Lockman & van den Steenhoven, 2002 ;  Vellerman et al., 2005 ) have substantiated the importance of close monitoring of adolescents’ exposure to risky environments where substance misuse is likely, particularly in high school and the transition to college. Close parental monitoring may be particularly important for adolescent COAs who are genetically sensitive to risky environments (e.g., teens with impulsivity and/or sensation-seeking temperaments).

The precise nature of risk or specific familial influences remains unclear.  Johnson and Leff (1999)  support earlier findings on negative outcome for COAs but caution that more rigorous longitudinal studies are required to provide definitive evidence for true deficits or developmental delays.  Menees and Segrin (2000)  found that adults who had a positive family history for alcoholism but did not have other significant family stressors reported no higher levels of family distress than adults who had a negative family history. An emerging literature has shown empirical support for the relationship between exposure in childhood to distressing parental problem drinking and the development of anxiety disorders and substance abuse in adult offspring. There is not a direct link, however, since this model identifies the mediating effect of anxiety sensitivity in this relationship ( MacPherson, Stewart, & McWilliams, 2001 ).

The child or children of an alcoholic, like the substance abuser or other family members, may need to be the target of intervention. The National Association of Children of Alcoholics developed care competencies that outline the knowledge, attitudes, and skills that a professional must have to meet the needs of children and adolescents affected by family substance abuse (see  Adger, 1998 ). There are three inclusive levels pertaining to the primary role of the professional: Level I: clinical care; Level II: prevention, assessment, intervention, and coordination of care; and Level III: long-term treatment. In short, all health care professionals should be aware of COAs’ complex and comprehensive needs.

Children of alcoholics often show remarkable resiliency in the face of potentially detrimental effects of parental alcoholism and grow into well-functioning adults. Family units in which a parent has an alcohol use disorder may also be described as resilient ( Coyle, Nochajski, Maguin, Safyer, DeWit, & McDonald, 2009 ). In fact, many COAs do not display alcoholism or other psychopathology in adulthood, while many non-COAs do exhibit these problems. Nevertheless, COAs often employ coping strategies (such as suppressing feelings), which may even appear adaptive in adulthood, but are not necessarily conducive to mature functioning.

Adult Children of Alcoholics

The psychosocial difficulties experienced by children and adolescents living with an alcoholic parent do not necessarily end as the individual matures. There is strong evidence that the vulnerability of many COAs extends into adulthood (Sher, 1997). According to the  Center for Substance Abuse Prevention (2010) , of the estimated 27.8 million children of alcoholics in the United States, about 16.8 million are adults over the age of 18.

As indicated above, in alcoholic families, there is not a free flow of emotional expression and open communication.  Black (1981)  coineda phrase that captures the powerful injunctions regarding behavioral and emotional expression in these families: “Don’t talk, don’t trust, don’t feel.” Further, these family environments are often characterized by other seriously dysfunctional behaviors that contribute to individual impairment, such as conflict, stress, violence, and child maltreatment. Parental alcoholism may or may not be related to adult impairment—in particular, the so-called adult children of alcoholic (ACOA) syndrome proposed by chemical dependency counselors. This syndrome refers to a behavioral and emotional pattern displayed by some individuals from families with a history of parental alcoholism and codependency characterized by a restricted range of affect and extreme distrust of intimacy ( Black, 1981 ,  1990 ;  Woititz, 1990 ). Although widely accepted in the chemical dependency field, the ACOA syndrome has not been validated through empirical research. Only a few studies have attempted to specify the individual or family characteristics associated with the ACOA syndrome ( Hawkins, 1996a ;  Hawkins & Hawkins, 1995 ,  1997 ).

The literature on the etiology of the ACOA syndrome lacks specificity. An internalized sense of shame is linked to the dysfunctional behaviors of many adults, including those who display the ACOA syndrome (and who may or may not be alcoholic). Individuals who grew up in “shame-bound” families, whether characterized by alcoholism or other pathology, are thought to often experience impairment in adulthood. However, coming from a family with parental alcoholism or other pathology is not sufficient for the development of characteristics of the ACOA syndrome. According to  Kaufman (1985b) , theory on the development of shame does not predict a particular pathogenic family process (i.e., alcoholism, incest, mental illness, etc.). He surmised that the model of a “shame-based” identity can be applied only to adults since it is presumed that children (less than age 18) have not fully developed a stable identity, healthy or otherwise.

Pathogenic processes in the family of origin are hypothesized to increase the risk of adult offspring establishing pathogenic family processes in their family of procreation. Studies suggest that the way in which rituals and routines are practiced in the family of origin may have either a detrimental or a protective influence on the development of alcoholism in offspring ( Bennett, Wolin, & Reiss, 1988 ;  Bennett, Wolin, Reiss, & Teitelbaum, 1987 ;  Wolin & Bennett, 1984 ;  Wolin, Bennett, & Jacobs, 1984 ;  Wolin & Wolin, 1993 ). In essence, these authors found evidence that families that had a breakdown of rituals were associated with lower levels of functioning in young offspring, higher levels of alcoholism in adult offspring, and lower levels of ritual practices by adult offspring in their family of procreation. Thus, a cross-generational pattern is established that perpetuates alcoholism and its related problems.

To conclude, definitional issues complicate an understanding of the emotional and behavioral patterns of alcoholism, codependency, COA, ACOA, and shame. These terms (and the constructs that they represent) are interrelated but are poorly defined; therefore, it is difficult to distinguish them from each other. Not all ACOAs meet the profile of codependency, nor are all codependent individuals from alcoholic or addicted families.  Hawkins and Hawkins (1995)  developed a measurement instrument, the Adult Children of Alcoholics Tool, to clarify these concepts (see  Box 10.1 ).

BOX 10.1 The Adult Children of Alcoholics Tool (ACAT)

There is evidence of the ACAT’s validity and reliability as a standardized self-report measure of current mental health functioning. It is hypothesized to reflect the internalization of shame and the negative attributes (inhibited emotional expression, difficulties with intimacy, and interpersonal distrust) characteristic of growing up in an alcoholic family ( Hawkins & Hawkins, 1995 ). None of the items in the ACAT mentions a drinking problem or alcoholism in the family of origin. This is because the ACAT was developed explicitly to measure the respondent’s endorsement or internalization of the core psychological attributes of the ACOA syndrome, not merely his or her identification with being the offspring of an alcoholic parent. The ACAT may be a useful tool for practitioners and researchers in assessing potential vulnerabilities in individuals with a family history of alcoholism. It has been shown to be a valid and reliable measure of the ACOA syndrome. This initial identification can then be further explored as part of an interview process. Individuals scoring 30 or above on the ACAT, when informally interviewed, most often reported that they had a sense of pathogenic shame or current mental health problems.

Directions

The following questions refer to your family of origin, the family with which you spent the most time when you were growing up. Indicate how strongly you agree or disagree with each statement by choosing the appropriate letter. Fill in the blank preceding each statement with the letter A, B, C, D, or E, depending on your choice: A = Strongly Agree; B = Somewhat Agree; C = Neutral; D = Somewhat Disagree; E = Strongly Disagree. Item scoring weights are as follows, corrected for reverse scored items: A = 3, B = 2, C = 1, D = 0, E = 0. ACAT total score = Sum of items 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, and 30.

Part I ACAT Items

1. I tend to not talk about the real problems in relationships with people I care about. *

* These items can be deleted to form a 25-item scale.

2. I try to take a lot of responsibility for people and things. *

3. When there is a problem in my family we can talk about it. (reverse scored)

4. The idea of loss of control is intolerable to me.

5. It is hard to share problems with people I love.

6. It is easy to trust members of my family. (reverse scored)

7. It is difficult for me to set aside responsibilities for awhile and enjoy play.

8. When I have a problem with someone I care about I am reluctant to discuss it, for fear of “rocking the boat.”

9. I find it easier to avoid situations where I have to take control in my family or personal relationships.

10. Consistency and predictability are usually the rule in my family.

11. I usually look out for others’ needs before my own.

12. People who know me might call me a compulsive giver. *

13. There is very little predictability in my family.

14. I have always felt comfortable bringing my friends home to meet my family. (reverse scored)

15. Ever since I was young I have learned to be tough and not to cry.

16. If I can just ignore a problem it will not hurt so bad and I can handle it easier later.

17. There is something about me that seems to attract needy individuals, or people with any kind of problem. *

18. I want to trust others, but it is so much easier just to rely on myself.

19. I have trouble following a project from beginning to end.

20. I tend to overreact to changes over which I have no control.

21. It doesn’t matter much to me whether others approve of my actions or not. (reverse scored)

22. When I start a new a project I usually have no difficulty finishing it. (reverse scored)

23. Deep down I have usually felt that I am quite different from other people. *

24. I have difficulty forming intimate relationships with others.

25. I have a strong need for others’ approval and affirmation of my actions.

26. It’s hard for me to decide when to get close to people and when to back off from them.

27. Telling the truth about problems is encouraged in my family. (reverse scored)

28. Sometimes I find it hard to draw a line between my feelings and the feelings of people who are close to me.

29. I have a tough time being honest about my feelings toward others.

30. There are times when I think that anyone who could love me is stupid or worthless.

31. I tend to keep a cool head during a crisis, while others are getting upset. *

32. My judgments of others are not nearly so harsh as my judgments of myself. *

Part II ACAT Items **

** Optional measures of problem drinking

1. My father drinks (or did drink) about            alcoholic drinks a week. (Note: One 12 oz. can of beer equals one 5 oz. glass of wine or 1.5 oz. of hard liquor.)

a. 0–1

b. 2–3

c. 4–5

d. 6–9

e. 10 or more

2. My mother drinks (or did drink) about            alcoholic drinks a week.

a. 0–1

b. 2–3

c. 4–5

d. 6–9

e. 10 or more

3. I drink (or did drink) about            alcoholic drinks a week.

a. 0–1

b. 2–3

c. 4–5

d. 6–9

e. 10 or more

4. Currently, or at any time in the past, which of the following biological relatives have been a “problem drinker”?

a. father

b. mother

c. father and mother

d. none

5. Currently, or at any time in the past, which of the following biological relatives have been a “problem drinker”?

a. paternal grandparents

b. maternal grandparents

c. paternal and maternal grandparents

d. none

6. Currently, or at any time in the past, I regard (ed) myself as a “problem drinker.”

a. yes

b. no

Note: Reverse-scored items are included to minimize response-set bias, since all items are answered either “agree” or “disagree.”

Source: R. Hawkins & C. Hawkins, Research for Social Work Practice (Vol. 5. Issue 3), pp. 317–339, copyright © 1995 by Sage Publications.

Assessment and Treatment of Alcoholic Families

There are many reasons for including the family in treating what has traditionally been viewed as an individual problem.  Wegscheider (1981)  identifies several ways that involving the family can benefit the alcoholic in his or her individual treatment: They can provide useful information about the patient, may be alcoholic or emotionally disturbed themselves (and negatively affect the patient if they are not treated), are likely to continue to enable the patient’s dependency if they do not receive assistance, and may help break the cycle of drug misuse in their offspring.

There are also reasons for focusing treatment on the family itself. It is unproductive to treat an individual separate from the system if he or she will be returning to live with the family. Family members are also under stress and probably in need of help, and only through participating together in treatment can the family truly understand its dynamics and develop new behaviors. There is some evidence that alcoholics show a better response to treatment when it includes family members, especially the spouse ( Collins, 1990 ).  Edwards and Steinglass (1995) , in a meta-analysis of 21 studies, conclude that family-involved treatment is particularly effective in motivating alcoholics to enter treatment. Such an approach allows the family to share a common goal and, even if problems continue, to perhaps experience some success in non-drinking areas of communication and interaction.

In family treatment, the goal of therapy is not only sobriety for the identified alcoholic but also improvement in family functioning.  Elkin (1984)  identifies five goals for treatment: (1) stop the drinking and/or isolate the drinking member, (2) stop life-threatening or destructive behavior of family members, (3) disengage children from parental roles and alter inappropriate parent/child alliances, (4) help re-form the parental alliance and authority, and (5) support members in obtaining necessary resources outside of the family.  Kitchens (1991)  recommends targeting inflexibility, boundary confusion, parent/child coalitions, scapegoating, inadequate communication, discounting feelings, and unhealthy rules.  Copello et al. (2005)  examined the literature on family interventions in the treatment of alcohol and drug problems and identified three broad categories: “1) working with family members to promote the entry and engagement of misusers into treatment; 2) the joint involvement of family members and misusing relatives in the treatment of the misuse; and 3) responding to the needs of the family members in their own right” (p.  371 ). In a review article,  Rotunda, Scherer, and Imm (1995)  state that successful family treatment of alcoholism requires addressing relapse prevention and the tendency toward conflict (including violence).

A family may enter treatment through several routes.  Lawson and Lawson (1998)  describe four ways that a therapist may come in contact with alcoholic families. First, a family may seek therapy with the undesirable behavior of a child or adolescent as the presenting problem, which may be substance abuse or a reaction to family dysfunction caused by hidden addiction in one or both of the parents. Second, a family may acknowledge a parental alcohol problem in which drinking does not lead to significant behavior changes, is not a source of major conflict, seems incidental to other problems in the family, and may diminish as other problems are addressed. Third, a family may present with alcoholism as the major problem such that the system is organized around the drinking, which is a source of severe conflict and intensifies other problems, and is typically of lengthy duration. Behavior changes in the alcoholic while drinking are extreme and frequent. Fourth, the family may seek help after the alcoholic has completed treatment, even years into recovery, due to new problems that have emerged or developmental changes.

Thus, families may enter treatment with or without the goal of directly addressing alcoholism in a spouse, parent, or child. Depending on the nature of the treatment they receive, the alcoholism may or may not be addressed. Since alcoholic families are quite adept at keeping their “secret” hidden, alcoholism may not surface unless the therapist looks for it. If the family acknowledges the problem but the alcoholic or addict does not, a process called intervention, developed by Vernon  Johnson (1998) , has been used to engage patients in treatment. There is limited empirical support for the effectiveness of this approach ( Loneck, Garrett, & Banks, 1996 ). A description of the Johnson Institute (JI) intervention technique is presented in  Box 10.2 . Ethical concerns have been raised about the JI intervention, primarily around the issues of coercion and confidentiality ( Conner, Donovan, & DiClemente, 2001 ). They contend that this technique requires further evaluation and offer a detailed description of several alternative approaches for engaging the substance abuser in treatment. The ARISE program (which stands for A Relational Intervention Sequence for Engagement) is a less confrontational but progressively more intense three-stage approach ( Garrett et al., 1997 ,  1998 ;  Landau et al., 2000 ). Conner et al. acknowledge that there is limited research on the effectiveness of this approach as well. They extrapolate from evaluation studies of interventions similar to ARISE, however, and suggest that this approach may be more effective than JI in terms of the rates of treatment entrance, completion, and relapse prevention.  Fernandez, Begley, and Marlatt (2006)  argue that JI and AA (the predominate help-seeking approaches in the United States) are more limited than ARISE and similar family-based interventions, and cite some empirical studies to support their position.

BOX 10.2 Intervention

Intervention is based on the premise that alcoholics who are in denial will resist any attempt to be engaged in treatment. Therefore, presenting them with the need for help must be done in a way that they can accept. Usually, conducted in conjunction with a specially trained professional, an intervention is a carefully planned and rehearsed procedure. In a nonjudgmental tone, significant persons in the alcoholic’s life (such as family members, friends, employer, doctor, etc.) confront him or her with firsthand, specific, behavioral feedback regarding how the alcoholic’s drinking has affected them. Once the alcoholic’s denial has been weakened by the reality of his or her behavior, the interveners present acceptable treatment options to the alcoholic, permitting him or her some input in the decision making. The alcoholic’s excuses for avoiding treatment have been anticipated, so they are less likely to be successful.

Loneck, Garrett, and Banks (1996)  provide a review of the literature on the effectiveness of the Johnson intervention as a therapeutic technique. They note that although the Johnson intervention (JI) is highly effective for engaging and retaining clients in inpatient treatment, the effectiveness for outpatient treatment and the differential impact of variations of the JI have not been evaluated. This review found that patients receiving JI were more likely to enter treatment than those receiving other methods of referral (coerced, noncoerced, unrehearsed intervention, and unsupervised intervention). Of patients entering treatment, those in the JI and coerced referral were equally likely to complete treatment and were more likely to complete treatment than the other groups.

Unilateral family therapy is another approach that targets the family to engage the substance abuser in treatment ( Thomas & Ager, 1993 ).  Conner et al. (2001)  identify that the primary goal of this three-stage approach is to improve the functional level of the family, which may in turn modify the substance abuser’s behavior, including his or her willingness to enter treatment. They note that while promising, this approach lacks sufficient empirical support of its efficacy. Finally, the authors describe the Community Reinforcement and Family Training (CRAFT) program, developed by  Meyers, Smith, and Miller (1998) . The primary goals of this approach are helping family members to encourage the substance abuser to stop drinking, to enter treatment, and to engage in better self-care. The training program occurs over several sessions, and if it is effective in getting the substance abuser to enter treatment, significant others continue active involvement through the family program. The authors note that the effectiveness of the CRAFT approach has been demonstrated through clinical evaluations.

Once the substance abuser has entered treatment, involving the family in the treatment and aftercare process appears to enhance effectiveness, regardless of the specific treatment approach used. Conner et al. describe two therapeutic approaches that include the family in treatment: behavioral marital therapy (BMT) and the community reinforcement approach (CRA). Both approaches are effective in that “contingency management and behavioral contracting, components of both BMT and CRA, have demonstrated empirical support” (p.  170 ). After treatment is completed, involvement of the family in the aftercare and maintenance stage leads to improved outcomes. They identify two primary family approaches for this stage: couple relapse prevention (a component of BMT) and self-help groups, such as Al-Anon.

Regardless of the specific approach utilized, to be effective the therapist must assess the stage of the family’s development in the addiction/recovery process, since the focus of intervention and prognosis varies accordingly.  Brown and Lewis (1999)  identify four stages (drinking, transition, early recovery, and ongoing recovery) and three domains of experience (the environment, the family system, and the individual) that must be considered. Similarly,  Buelow and Buelow (1998)  present a developmental model based on three stages: early abusive, middle dependent, and late deteriorative. In both models, key tasks of the therapist are noted for each stage. Conner et al. synthesize theory and research on addictive behavior change, using the  Prochaska, DiClemente, and Norcross (1992)  five-stage process model of precontemplation, contemplation, preparation, action, and maintenance. Although this model is based on the individual, the authors observe that “the family, in its response to the substance abuser’s behavior, is likely to go through stages of readiness to change that parallel those of the substance abuser” (p.  150 ).

In counseling families, as opposed to counseling individuals, specific ethical concerns need to be considered.  Whittinghill (2002)  points out that ethical guidelines have not kept pace with the rapid expansion of family therapy as an approach to substance abuse treatment.  Benshoff and Janikowski (2000)  discuss several concerns, some of which are common to family therapy, such as handling secrets, using diagnostic labels, and addressing conflict. In addition, special concerns may emerge in counseling chemically dependent families, especially around informed consent and confidentiality. There may be an expectation of family involvement by treatment agencies and the criminal justice system, but family members may not want to participate. Finally, the authors note the need for therapists to engage in ongoing self-awareness and values clarification, since chemically dependent families often present with complex and challenging problems.

A family-oriented perspective in the treatment of alcoholism does not imply that the family caused the problem. In fact, as noted throughout this book, there is likely no single cause of chemical abuse or dependency. These problems may arise from and be maintained by a combination of biopsychosocial factors in the individual, family, and community. A family-oriented approach conceptualizes the problem in terms of family functioning and directs treatment at that level. Although differing theoretically, each of the models presented here recognizes that interactive patterns maintain the drinking and contribute to family dysfunction. Therefore, each advocates family involvement in some aspect of treatment and contends that any changes will affect the system, not just individuals.

Behavioral Perspective

A behavioral approach to working with couples or families is based on principles of behavioral theory. Such principles can be used either as behavioral therapy of families or as a model of family therapy that utilizes behavioral principles (see the next section). Briefly stated, behavioral theory argues that virtually all behavior is learned (as opposed to inborn) and maintained (or conditioned) through environmental or social consequences, such as reinforcement. Social learning theory and cognitive-behavioral theory add to the conditioning theories by recognizing that cognitive processes, such as modeling, mediate between the individual and the environment.

How does behavioral therapy apply to chemically dependent families? These families often attempt intuitively to use positive reinforcement (reward drinking behavior through attention or caregiving), negative reinforcement (protect the chemically dependent individual from the negative consequences of alcohol or drug use), or punishment (inflict a penalty on the person for drinking or drugging) ( McCrady, 1986 ). Unfortunately, each of these responses is considered to increase the likelihood of drinking. Behavioral therapy, on the other hand, attempts to apply the principles of reinforcement to achieve desirable results. “The guiding principle of the application of behavioral techniques in family treatment of alcohol abuse is to increase and reinforce positive behaviors/interactions among family members and to decrease negative behaviors/interactions related to drinking” ( Collins, 1990 , p. 288). Another application of behavioral theory to family treatment is modeling. For example, the therapist can model more functional interaction with the alcoholic for family members, and the non-abusing spouse can model more appropriate drinking behavior for a non-abstinent individual ( O’Farrell & Cowles, 1989 ).

Behaviorally oriented family treatment differs from systems-oriented family therapy in several important ways. Treatment begins with a behavioral assessment of family difficulties, which identifies specific areas to target for intervention, as well as a careful analysis of antecedent and consequent events. Assessment is an ongoing process, and intervention is modified in response to changing behaviors. Treatment is directed at observable behavior, and there is no effort to address intrapsychic processes or interpersonal patterns (other than those specifically related to the target behavior). The causes and effects of the problem are seen as linear rather than circular. Further, the behavioral approach tends to focus on dyadic interactions rather than triads. Families are often educated in the principles of behavior therapy so that they can monitor and modify their own behavior and interactions.

Behavioral couples therapy (BCT) is the most common application of the behavioral perspective with families in the substance abuse field. It is demonstrably cost effective, since it reduces alcohol-related time spent in the hospital or jail, which is far more expensive than providing therapy.  O’Farrell and Fals-Stewart (1999)  state that in contrast to other family approaches, which are widely used but not well researched, the behavioral approaches have strong empirical support but are not widely used. There is a rapidly expanding empirical literature verifying the effectiveness of BCT (e.g.,  Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009 ;  Winters, Fals-Stewart, O’Farrell, Birchler, & Kelley, 2002 ).  Fals-Steward et al. (2009)  state that multiple studies over the last30 years have consistently found the following benefits of BCT compared to individual therapy or partner-involved control groups: 1) reduced substance use, 2) improved relationship satisfaction, and 3) greater adaptive functioning (less partner violence and better custodial child adjustment).

Stress-Coping Perspective

The stress-coping and behavioral models are similar in many respects. Both were first used to address addiction in the individual, and both have been expanded to include marital and family relationships. Like the behavioral and systems perspectives, the stress-coping perspective recognizes the reciprocal nature of family interaction. However, it differs from the family system perspective since it does not view the family as a unit unto itself. Rather, the family is viewed within a larger comprehensive approach encompassing the stress, resources, and coping of individual members. For the alcoholic, this theory contends that “substance use represents an habitual maladaptive coping response to temporarily decrease life stress and strain” ( Hawkins, 1992 , p. 161).

Stressors may or may not precipitate drinking; this depends on a number of factors. For example,  Cronkite, Finney, Nekich, and Moos (1990)  identify factors that interact to influence the recovery process for the alcoholic, such as demographic characteristics, personal resources, prior functioning, treatment program and experiences, life context, and coping responses. This model can also help to understand the functioning of other family members, although treatment variables would be less directly relevant. According to Cronkite and colleagues, “An alcoholic’s life context can provide a supportive milieu for continued improvement, cushion the impact of stressors, or trigger a relapse” (p.  309 ). For the spouse and children of an alcoholic, other factors in their lives besides the alcoholic’s behavior must be considered in order to help them to adapt better, such as environmental factors, life stressors, and the functioning of the individual or other family members. For children, this particularly refers to the non-alcoholic parent.

Family involvement using the stress-coping approach can vary widely ( Wills, 1990 ). Al-Anon can be viewed as using this model in that it emphasizes the development of skills for coping with the stress of dealing with an alcoholic loved one. Al-Anon members are encouraged to find satisfaction through their own pursuits.  Edwards and Steinglass (1995)  note that, while Al-Anon is the most commonly implemented aftercare program for families, there are no systematic data on its long-term effectiveness. In addition to Al-Anon, family members can learn more adaptive coping through individual therapy. These individual efforts, in turn, can have the added effect of facilitating changes in the alcoholic, since change in one member affects the whole system. Marital or family-oriented treatment assists members in identifying personal and familial stressors that impede the recovery process and shows them how to develop more adaptive cognitive and behavioral coping mechanisms, communication patterns, and problem-solving skills.  Wallace (1985)  identifies five coping mechanisms often employed by the spouses of alcoholics that may actually encourage continued drinking: (1) withdrawal, (2) protection of the alcoholic, (3) attack, (4) safeguarding family interests, and (5) acting out. Encouraging the spouse to identify more effective strategies can be a complex process, since “the effectiveness of a particular coping skill will vary, in all likelihood, with (1) the situation itself, (2) the individual alcoholic, (3) the characteristics of the spouse, and (4) the strength and cohesiveness of the marital bond” ( Rychtarik, 1990 , p. 357).

Family Therapy Perspective

Family therapy can be contrasted to individual therapy, which views problems as internal. Family therapists “believe that the dominate forces in our lives are located externally, in the family. . . . When family organization is transformed, the life of every family member is altered accordingly. [Over time, this process] continues to exert synchronous change on each other” ( Nichols, 2009 , p. 5). Family therapy (including marital therapy) represents a shift from viewing people as individuals to viewing them through their relationships to others. Models of family therapy have been classified using several different theoretical frameworks, such as Bowenian, strategic, structural, experiential, psychoanalytic, cognitive-behavioral, solution-focused, and narrative. Although the models share a family systems theoretical orientation, they differ in terms of conceptualization of the problem, specific goals of treatment, strategies and techniques, and role of the therapist. (For a discussion of these models, see any basic family therapy text, such as  Nichols [2009] .)

Until recently there has been no model of family therapy designed specifically to address addiction ( Steinglass, 1987 ,  2009 ). Rather, the philosophy, goals, and strategies of each model are applied to alcoholism as the presenting problem indicative of underlying dysfunction in the family system. The behavioral or stress-coping perspectives focus directly on the alcohol-related behaviors of family members, whereas the family therapy perspective focuses more on the nature of the relationships among family members, which may not be unique to alcoholism.  Collins (1990)  states that, “the specific nature of the individual’s impairment may be a less potent contributor to family dysfunction than is the fact that the family contains an impaired member” (p.  304 ). Several authors provide clinical guidelines using a family systems perspective (e.g.,  Lawson & Lawson, 1998 ;  Lawson, Lawson, & Rivers, 2001 ;  McCollum & Trepper, 2001 ;  Perkinson, 2002 ). For example, Lawson and Lawson address the commonly related problems of family violence, sexual dysfunction, and divorce. McCollum and Trepper examine four areas in which family therapy has been misunderstood by the general public and many mental health professionals: parental blame, biologically-based disorders, the disease model of addiction, and differences in terminology.

Steinglass and colleagues (1987)  emphasize that alcoholic families are highly heterogeneous (as are families with an alcoholic member). They believe that “it is no more credible to propose that a single treatment approach will make sense for each and every alcoholic family than it is to assume that all alcoholic families follow comparable developmental courses or manifest the same personality features” (p.  364 ). Therapists are also heterogeneous and should match their family therapy approach to their personality, individual style, and family background ( Kaufman & Kaufman, 1992 ).

Steinglass et al. (1987)  provide a four-stage model, briefly highlighted here, for working with alcoholic families. The first stage is a careful assessment in which overall family functioning is evaluated (including the role of alcoholism) and the primary problem is identified and defined at the family level. The assessment, to determine if the system represents an alcoholic family or a family with an alcoholic member, can be accomplished through an interview focused on family rituals to ascertain the extent to which they have been invaded by alcoholism. If the family has become organized around alcoholism,

a treatment program that leads to a cessation of drinking on the part of the family’s alcoholic member will, in such families, have profound implications at almost every level of family life. Thus, in such situations, overall treatment success is likely to depend not only on efforts aimed at alcoholism per se, but also on a comprehensive approach to dealing with the family-level implications of the cessation of drinking (p.  333 ).

The developmental phase of the family also needs to be ascertained since this has implications in terms of treatment goals and outcome criteria. Alcoholism may or may not be the presenting problem for a family. Families often seek help when they are in the midst of a developmental crisis. It is possible for a family to resolve their developmental crisis without eliminating the drinking. For example, they describe a family making the transition to the later stage of its development. At this stage, one of the family’s developmental tasks is to launch adult children into age-appropriate roles. The family successfully achieved this goal even though the parents’ drinking pattern remained unchanged.

The outcome of the assessment determines the course of treatment. For an alcoholic family, therapy must target the alcoholism first and then the presenting problem (if it remains after the alcoholism is addressed). For a family with an alcoholic member (i.e., not organized around alcohol), the problem as presented by the family becomes the focus of treatment. The alcoholism may be addressed within this context, using traditional family therapy techniques.

On the other hand, if alcoholism is identified as the problem, the second stage is referred to as family detoxification,which consists of eliminating alcohol from the family system. The authors recommend that the therapist use a problem-solving approach, which entails contracting with the alcoholic to stop drinking (including completing a medical detoxification regimen, if necessary) and identifying responsibilities for each family member. The alcoholic may refuse to acknowledge a problem and to detoxify, yet the family may still decide to continue treatment. If so, the alcoholic is excluded from the therapy. Examples of tasks in the contract are removing alcohol from the home and reinstating family routines. The therapist should anticipate difficulties in negotiating and implementing the contract, since the family is attempting to change instilled patterns.

Following successful completion of the assessment and detoxification stages, drinking is no longer considered the major issue. The next two stages address family interactional patterns, using any one of the models of family therapy. The third stage addresses the family’s emotional instability that follows when drinking no longer occurs in a family that has been organized around alcohol. The task of this stage is to assist the family in tolerating this shift and in establishing new patterns that are not tied to alcohol. A psychoeducational approach explaining the difficulty of making these changes can be very helpful.

The fourth stage, in which the family consolidates changes, can result in two possible outcomes. In the first, called family stabilization, the interactional patterns remain essentially unchanged, but the family no longer relies on drinking to regulate them. Alternatively, family reorganization occurs when the family fundamentally alters its interactional patterns.

The foregoing framework is a general guide, since it is possible that a family will drop out of treatment at any stage. Further, a family may slip back into alcohol use at some point. In the latter instance, the therapist can renegotiate a detox contract and support the family in continuing to make changes. A family systems approach is not always the treatment of choice, since family members are not always available. In addition, family therapy does not eliminate the need to include individually oriented interventions in the treatment, such as AA or Al-Anon.

Steinglass (2009)  has refined his family systems treatment model for substance abuse to include motivational interviewing, calling this newly integrated approach systemic-motivational interviewing (SMI). Motivational interviewing was developed in the 1980s as an alternative to confrontational techniques that were widely used in the United States but deemed ineffective. It is regarded as more humanistic and consistent with harm reduction and relapse prevention approaches. Preliminary data indicate it is effective with individuals, but there is no research on couples or families. Since SMI is based on prior empirical evidence of both family therapy and substance abuse treatment, Steinglass contends that it has strong face validity. SMI specifically targets the underlying belief system, particularly regarding ambivalence about change, felt by all members of the family. In this model, there are three stages: assessment and consultation, family-level treatment, and aftercare and relapse prevention. Steinglass postulates that one promise of this model is that it “potentially bridges the divide currently separating the worlds of family therapy and substance abuse treatment” (p.  171 ).

Effectiveness of Family Treatment

As discussed in Chapter 6, data on the effectiveness of treatment for alcoholism are often equivocal, as relapses rates remain high. This same pattern applies to studies that examine the effectiveness of family-level intervention, although there is general support for the positive outcomes of family therapy for alcoholism and substance misuse (e.g.,  Edwards & Steinglass, 1995 ;  Steinglass, 1987 ,  2009 ;  Steinglass et al., 1987 ). Although acknowledging limitations of the data, these authors point out that no other treatment has been shown to be any more effective in producing desirable changes in behavior.  O’Farrell, Murphy, Alter, and Fals-Stewart (2008)  observe that “meta analytic reviews indicate that involving the family in the patient’s treatment generally is an effective means to promote recovery from alcoholism and drug abuse” (p.  464 ). In another recent review,  Copello, Velleman, and Templeton (2005)  also conclude that family involvement in substance misuse treatment can be very effective.  Austin, Macgowan, and Wagner (2005)  summarize family-based intervention approaches that have shown promise in early controlled studies, but add that these findings require replication by independent investigators. They also note (as do  Crespi & Rueckert, 2006 ), that family therapy can only be effective if it is implemented properly; both articles call for clinicians to be properly trained.

There are several earlier noteworthy studies of family-oriented approaches that indicate effectiveness.  Edwards and Steinglass (1995)  “reviewed findings from twenty-one studies investigating the efficacy of family therapy as a treatment for alcoholism and found evidence to support the potential usefulness of including family members in all three phases of alcoholism treatment—initiation of treatment, primary treatment rehabilitation, and aftercare” (p.  500 ). No single family therapy approach was shown to be more effective, and some family variables influenced the findings (i.e., gender of the identified alcoholic, commitment to and/or satisfaction with the marriage, and spousal support for abstinence).  Liddle and Dakof (1995)  examined controlled treatment outcome research of family therapy for drug abuse in both adolescents and adults. They found “family therapy . . . to be more effective than other treatments in engaging and retaining adolescents in treatment and reducing their drug abuse” (p. 521), although only one study provided support in the adult area.  Stanton and Shadish (1997)  conducted a meta-analysis of 15 experimental studies of couples and family therapy in treating substance abuse. They found that family therapy was more effective than individual therapy, peer-group therapy, or family psychoeducation. Family therapy also proved to be effective for both adolescents and adults. Involvement of family members was significantly effective in reducing drug use and treatment dropout rates as well as in increasing the length of participation in treatment. The authors attributed this finding to the more supportive stance of family therapy as opposed to the more confrontational approach of traditional chemical dependency interventions.  Lipps (1999)  reviewed the literature for family therapy with alcoholism, comparing the efficacy of the behavioral versus the family systems approach, and found that neither proved superior. On the other hand,  O’Farrell and Feehan (1999)  reviewed the literature on behavioral couples therapy and found that it was associated with improved family functioning, which in turn was linked to better mental health and psychosocial functioning in the offspring.

Additional studies continue to support this overall trend toward effectiveness.  Carise (2000)  found that family involvement in treatment significantly increased the likelihood that cocaine and alcohol abusers would complete the full course of treatment, although the author did not evaluate the impact of family involvement on continued recovery.  Thomas and Corcoran (2001)  conducted a meta-analysis of empirical studies with adult subjects comparing two spouse/family intervention approaches, either with the abuser’s involvement (primarily behavioral couples therapy) or without the abuser’s involvement. Findings indicated that “family members can successfully affect the substance user’s behavior in terms of inducing them into treatment and reducing chemical use” (p.  570 ).  Stanton (2004) reviewed 19 outcome studies on engagement into treatment that compared substance abusers alone to substance abusers and a concerned person (since the vast majority of substance abusers either live with their parents or maintain close contact). The findings indicated the clear value of including family members in the engagement process, especially since only 5–10 percent of alcoholics or addicts in any given year engage in treatment or self-help groups.

Despite the clinical appeal of support groups as a resource for families with an alcoholic member, there is limited research on the efficacy of this approach ( Keinz et al., 1995 ).  Richter, Chatterji, and Pierce (2000)  examined the literature on the relationship between Al-Anon membership and certain components of adaptive life functioning. They reviewed three correlational studies— McBride (1991) ,  Humphreys (1996) , and  Keinz et al. (1995) —in addition to their own qualitative study. The findings suggest the effectiveness of Al-Anon in helping family members. One unique component of a day treatment program for substance abusing adolescents, called Pathway Family Center, placed early stage abstinent teens in cross-fostering “host homes” to extend the protective 12-step sponsorship to 24 hours per day ( Deskovitz, Key, Hill, & Franklin, 2004 ). The apparent effectiveness of this innovative component remains to be validated in a controlled study.

Finally, a critical aspect of effectiveness in family-level treatment of substance abuse pertains to special populations. While there is a growing literature on family therapy with diverse populations, there is limited empirical research specific to substance abuse issues.  Delva (2000)  explores culturally-specific family-oriented substance abuse treatment interventions, considering group affiliation based on race/ethnicity, gender, age, class, and sexual orientation.  Cuadrado and Lieberman (2002)  address traditional Hispanic family values and substance abuse prevention and intervention. The Treatment Improvement Protocol 39 on substance abuse treatment and family therapy addresses special populations, including rural populations ( Center for Substance Abuse Treatment, 2004 ). Further, clinicians must be skillful in assessing and treating clients with co-occurring psychological disorders and addictive behaviors ( Barrowclough et al., 2001 ;  Clark, 2001 ;  Mueser et al., 2009 ;  Rotunda and O’Farrell, 1997 ; see also  chapter 13 ).

Case Example

The following case example illustrates some main points emphasized in this chapter, particularly regarding the family therapy perspective (e.g.,  Steinglass, 1987 ;  2009 ). The names and significant data for the family have been altered. There is considerable variation among families, therapists, and modalities; this case represents only one possible approach. Since it does not describe specific intervention techniques employed, such as family sculpting (originally developed by  Duhl, Kantor, & Duhl, 1973 ), an illustration of applying this technique with the family is provided in  Box 10.3 .(While this case pertains to an Anglo family,  Wycoff and Cameron (2000)  provide a case study of a Hispanic family.)

Presenting Problem

Emily is a white, 18-year-old high school senior. She was admitted to City Psychiatric Hospital in December following a suicide attempt. She had no history of prior psychiatric treatment or difficulties. She presents as an attractive, intelligent, and cooperative adolescent. Behavioral and emotional problems emerged one year ago and escalated rapidly: conflict with her parents over money, studying, household duties, and curfew; school failure and truancy; depression; and social isolation. If these problems persist, she will not graduate in May.

While in the hospital, Emily revealed extensive substance abuse, primarily alcohol, but occasional use of marijuana, cocaine, and “pills.” She would use “whatever was available.” She began drinking two years ago and reported that she “loved” alcohol, both the taste and the way it made her feel. Typical use consisted of daily drinking and weekend binging to the point of intoxication. She successfully hid her drinking from her parents. She described them as “preoccupied with their own problems.” Emily feels that her father abuses alcohol. She claims that her suicide attempt, mixing alcohol with barbiturates, was an accident. It occurred after her boyfriend broke up with her and she felt “sad and lonely.”

After being evaluated in the hospital, Emily was transferred to a residential treatment program for adolescent substance abusers. She seems to have benefited from this treatment in that she now describes herself as “in recovery.” She realizes that she must remain abstinent, and she attends several AA meetings a week. She meets regularly with the high school social worker and participates in a weekly peer support group. Although she feels that she is “turning her life around,” conflict has continued with her parents. She and her family were referred to Mental Health Clinic for one hour a week of outpatient family therapy following her discharge from the treatment program.

BOX 10.3 Family Sculpting

Family sculpting is an experiential technique used by family therapists to visibly display the dynamics of a family. It allows the family to experience themselves in an active way, rather than passively discussing their relationships. Using spatial distance and physical position, one member of the family arranges the other members in relation to how he or she perceives the family’s dynamics at a particular point in time. Family members are usually instructed not to speak as they complete the exercise. This nonverbal technique can be especially useful if family members seem reluctant to express their feelings or if they are unable to describe their perceptions. It can be a creative way to pull out a silent member, take full advantage of a particularly perceptive member, or bypass familiar verbal patterns. Prior to beginning, the therapist should briefly explain the process and engage the willingness of members to participate.

Consider the family described in the case example that began on page 277. Assume that Emily is the sculptor and that this exercise is being used early in therapy, before any significant changes have occurred. Emily might be asked by the therapist to arrange the members of the family in a scene depicting a typical evening at home in the present. Imagine that Emily motions to her mother to stand in one corner of the room facing the wall. She indicates that her father should stand in another corner facing the wall. She positions her brother in the third corner facing the wall. Finally, Emily places herself in the fourth corner of the room, also facing the wall. This sculpture graphically shows Emily’s perception of the family as distant and disengaged. When they discuss the sculpture, the family might acknowledge the effect of not eating dinner together and isolating themselves in separate rooms. Thus, the sculpture conveys the powerful sense of loneliness and lack of support that Emily feels.

Through sculpting, a family might gain awareness and sensitivity in a way that would not be possible through a verbal exchange. As a result, they might be better able to modify interactional patterns. Applying the family principles discussed in this chapter, it appears that this family is an alcoholic family in the sense that alcoholism has been allowed to invade family rituals, such as eating and spending time together. The family has assumed rigid rules and roles that perpetuate the alcoholism and do not support the health and growth of individual members or the family as a whole.

Sculpting can be implemented in many variations. For example, Emily might be asked to sculpt the family again, this time depicting how she would like them to relate. Imagine in this case that she brings them together in circle at the center of the room, close together but not touching and facing each other. This could lead to further discussion about how they can change roles, rules, and so on. Alternatively, sculpting could be used at the end of the family therapy to show progress made. In another variation, a different family member could sculpt the family to show his or her perceptions. Someone could sculpt the family at a time before the alcoholism invaded the family’s rituals and they interacted together. The therapist could even sculpt the family, if needed. Sculptures can become quite complex with large nuclear and extended families, especially if there have been major disruptions over time. Members often become quite enthusiastic and creative in sculpting.

Family History

Other family members are the father, Jim, an accountant (age 42); Susan, a homemaker (age 42); and Jason, a high school freshman (age 15). They are a white, middle-class family. Both Jim and Susan described their family of origin as traditionally suburban middle class, with a breadwinner father and homemaker mother. They met in college, married immediately after graduation, and had their first child two years later. Jim described his father as a steady drinker, who was frequently verbally abusive. In retrospect, Jim believes that his father drank heavily throughout Jim’s childhood and adolescence, although he believes that his mother protected him and his older brother from much of their father’s alcoholic behavior. Susan reported that there was considerable conflict between her parents, who divorced when she was 16 years old. She rarely saw her father after the divorce. She reports no substance use by her parents.

The couple described their marriage as “average,” although closer inspection reveals that they seldom interact. Jim, who is self-employed, has been focused on his business over the last few years. The struggling local economy had severely cut his income. Susan is actively involved in several charity and social organizations. They acknowledged having “drifted apart.” In fact, there is little indication that the family as a whole has much interaction, since they do not eat meals together and spend most of their time in separate rooms. Jim acknowledges that he has three to four drinks a night but does not see this as a problem. Susan confirms this intake and feels that Jim’s drinking is a way for him to relax, given his work stress. Susan drinks socially on occasion. Jason denies any drinking or drug use, and his parents believe that this is an accurate report.

Assessment

According to a family systems perspective, Emily is the “identified patient” in this family. Although she clearly has an alcohol abuse problem in her own right, underlying factors in the family appear to be contributing to her difficulty as well as to that of other family members. One pattern observed in this family is triangulation. This concept can refer to the tendency of a marital dyad to maintain stability in their relationship by focusing their attention on a third person, usually a child. When a child experiences difficulties, the parents’ attention is diverted away from addressing the underlying problems in their relationship. From a systems perspective, all family members are participating in this pattern with the goal of reducing stress and conflict. Emily’s problems could be seen as a way to keep her parents engaged with each other through their mutual concern for her. Thus, they are spared from having to confront the lack of emotional support in their marriage. Developmentally, Emily is at an age when she should be starting to emancipate. This pattern may also serve to keep her in a non-adult role with her parents.

This family presents with at least three generations of active substance abuse. Jim is likely the adult child of an alcoholic father and a codependent mother and appears to be in denial regarding his own alcohol abuse problem. One could hypothesize that he learned the “don’t talk, don’t trust, don’t feel” rules that are often encountered in these families. It is not surprising that he is having difficulties with intimacy in his marriage and with his children. Susan suffered a severe blow to her sense of security when her parents divorced and her father became distant. She may not recognize the potential for a similar outcome in her own marriage. They have evolved into a classic male alcoholic, female codependent pattern in which both minimize the extent of problems that alcohol is causing in their family. They are locked in behavioral patterns that are self-defeating and are actively training their children into these roles as well. It appears that alcoholism accounts for the lack of shared rituals and routines in their daily life. Thus, according to the Steinglass model, they can be described as an “alcoholic family.”

Treatment

From a systems perspective, the focus of therapy will be on improving family functioning for the benefit of all family members. Since there is apparent active alcohol abuse in two family members (Emily and Jim), this will be the initial focus of treatment. Although Emily is engaged in a recovery program, numerous factors combine to jeopardize her sobriety as well as the well-being of other family members, including Jim. These include the continued presence of alcohol in the home (despite her clear request that it be removed), her father’s unwillingness to admit to his own alcohol abuse, ongoing conflict with her parents, and the general lack of emotional support in the family. Therefore, the therapy begins with the immediate goal of cessation of Jim’s drinking and removal of alcohol from the home. Once this is addressed, the goal will become to assist the family in developing patterns of interaction and communication that foster the growth of all family members. The therapy will be conducted following the four-stage model of  Steinglass et al. (1987)  discussed earlier in this chapter.

Stage one is diagnosing alcoholism and labeling it as a family problem. In the initial session, the therapist assesses the family functioning by questioning each family member in order to gain information as well as establish a therapeutic relationship with them. Jim and Susan adamantly insist that Emily’s oppositional behavior is the source of their family’s current problems. They feel that otherwise they would be “fine” and cite their previous successful functioning prior to Emily’s difficulties as evidence of their position. Emily remains noticeably sullen throughout the session. Jason seems to make every effort to appear invisible and grudgingly agrees with his parents when asked for his perspective.

In the next session, Emily becomes more vocal. She had met with her school social worker who urged her to share her concerns about her father’s drinking and her mother’s acquiescence in family therapy. She defiantly reports that her father is an alcoholic and that “I should know.” She and Jim immediately become entangled in a conflict. He denies that he has a problem and accuses her of trying to shift the blame for her behavior. Susan and Jason watch in silence, with evident discomfort. When questioned by the therapist, Susan expresses concerns for Jim’s health, revealing her fear that he will have a heart attack due to the stress of their financial situation. She apparently attempts to deflect the focus back to Emily by adding that their daughter’s difficulties have exacerbated his stress. When questioned again about Jim’s drinking, she seems to minimize it by stating that he just drinks to relax.

The family is in a standoff, and it is crucial for the therapist to address this impasse openly. She presses Jason for his opinion, since the silent member of a family is often the most valuable source of information. He reluctantly agrees with both Emily’s and Susan’s concerns: He thinks his father drinks too much and also worries about his health. With Jason’s revelation, Susan’s resolve to protect Jim in his denial appears to weaken. Although she continues to waver, she and the children gradually align in their concern about Jim’s drinking. They identify the following problems: embarrassment when he is drunk in public, anxiety when he wants to drive while intoxicated, fear of his angry outbursts, sadness over his emotional unavailability, concern regarding his poor health, and worry over financial instability.

Jim becomes increasingly defensive and the therapist moves to keep him engaged in the therapy. She reframes this feedback in terms of his family’s honesty: Although painful, it is an indication of their love for him. She commends him for having developed such a sense of trust with his family that they were willing to be so honest. It should be noted that the therapist is not labeling Jim as alcoholic at this point. Rather, she is keeping the focus on the family members’ current topic and facilitating their efforts to state directly how his drinking is causing problems in their family. This strategy reduces the possibility that the father will attack the therapist, be supported by family members, and manage to avoid this issue. The session concludes with the therapist clearly stating that Jim’s drinking seems to be a major problem for the family.

On the third session, the family comes in with a crisis: Jason had gotten into a fight at school and was suspended. Some crisis was almost to be expected, since the family homeostasis had been disrupted last week. One could hypothesize that Jason (perhaps unconsciously) was assisting Emily in maintaining the family’s familiar patterns, particularly in terms of keeping the focus off Jim’s drinking. The therapist quickly moves to counteract this attempt to regain stability by using a psychoeducational approach with the family. She explains the idea of “family system” and how the behavior of each member affects the family as a whole. She observes that the last session disrupted their usual patterns and notes how distressing this can be. This shows that she is empathic with their situation, places this crisis in a larger context, neutralizes the diversion, and enables her to return the focus to Jim’s drinking.

A long silence is broken by Jim’s query as to whether the therapist thinks that he has a drinking problem. Aware of the importance of this juncture, she responds that this certainly seems to be the case, based on behavioral indicators, but primarily because she has heard the concerns of his family and cannot disregard them. Since his attendance at this session indicates how strongly he is committed to his family, she is sure that he has heard their concerns as well. (This response puts Jim in a bind, since to disagree with the therapist would suggest that he is disregarding the concerns of his family and would call into question his commitment to them.)

Jim does not respond and is obviously distressed by his predicament. Susan tries to “rescue” him by stating her concern about the problems involving Emily and Jason. The therapist explains that she has not forgotten this, but that Jim’s drinking must be addressed first if the family is to resolve other problems successfully, especially since Emily is already engaged in treatment. They are reluctant to confront him further so, rather than engage in a power struggle with the family, she wonders aloud at the “power” that alcohol seemed to have over them. Jim breaks the silence, defiantly saying that alcohol has no power over him. She asks why he thinks that his family is so threatened by the topic (in this way, she highlights the process of alcoholism in the family, not Jim’s alcoholism, per se). This provides a less threatening avenue for Susan, Emily, and Jason to once again talk to Jim about his alcohol abuse and the effect it has on them.

In the next session, Jim indicates the effect that his family’s disclosure had on him. He was quite withdrawn during the ensuing week. He attempted to prove them wrong by showing that he could quit drinking whenever he wanted. However, in the face of his family’s feedback and the unexpected struggle he had in avoiding alcohol, Jim reluctantly agrees that he might have a problem. At this point, several significant events have transpired in the therapy: Jim’s denial regarding his alcohol abuse has been broken and his problem has been placed within the larger context of the family. The therapy enters stage two: removal of alcohol from the family system.

The family and therapist agree to work together to help Jim stop drinking. The next step is to develop a detoxification contract with the entire family, since this is now regarded as a family problem. Since hospitalization is not indicated, the therapist recommends an eight-week outpatient program (only a therapist adequately trained in assessment should make treatment recommendations). Jim agrees to make an appointment with this agency for an evaluation prior to the next session. He will also remove all alcohol from the home. Jim asks that the family spend more time together and feels that this will assist him in not drinking. He becomes tearful as he talks about how he feels uninvolved in his children’s lives (the therapist notes that he did not include Susan in this sentiment). The family agrees to have dinner together in the evenings. The therapist praises the family for their courage in confronting this problem together, acknowledges the difficulty of their task, but reassures them that they can succeed in making desired changes.

The therapist begins the fifth session by reviewing the family’s implementation of the detox contract. Jim has removed all the alcohol from the house, enrolled in an outpatient treatment program, and abstained for the full week. Family members confirm that he has not appeared to drink. However, they did not share any meals together. Susan, although expressing her relief over Jim’s adherence to the contract, feels that he has become more “moody.” Jim admits to feeling unsupported by the family, particularly since Susan has not organized any meals. Susan says that there were too many different schedules among them to plan a specific time for dinner (i.e., disruption of routines). The therapist anticipated problems with the contract, since the family is attempting to change entrenched patterns. She empathizes regarding the challenges they face, commends them for their successes, and assists them to negotiate a better plan. After considerable discussion, all members agree to adjust their schedule to have dinner together three times a week and to participate in the family component of Jim’s outpatient program. (It is important to recognize that the process of assisting them to develop new skills for problem solving, such as negotiation, is as important to the therapy as the product, the new contract. The therapist also notes the weak unity and authority in the parental dyad. Thus, she is continually engaged in assessment, gathering information that will be useful when they begin to address non-alcohol-specific family patterns.)

The next week, Jim enters treatment, and for six weeks, his behavior indicates that he is clearly engaged in his treatment program. He expresses a sense of camaraderie with other males that he has not enjoyed since being in the military. Nevertheless, he is finding it difficult not to drink and relies heavily on AA meetings and his sponsor for guidance. The family is actively involved in the family program. Emily is particularly enthusiastic, given her previous positive experience with treatment. She and her father have fewer conflicts as they support each other in their recovery efforts. Jim becomes more involved in Jason’s sports activities. The children have developed a habit of “checking in” with Jim at least once a day. Jim frequently expresses regret that he was not more available to them due to his drinking. The family is managing to have three dinners together a week and is trying to share one activity on the weekend.

As Jim maintains sobriety, the therapy shifts into stage three: the emotional desert. Jim is six weeks into his treatment and has been sober for two months. The focus of therapy is to support the family as they adjust to the absence of alcohol in the family system and to tolerate these changes. For years, they have slowly altered their behavior to accommodate Jim’s drinking. In turn, family members have developed maladaptive behavior, such as Emily’s drinking, Susan’s codependence, and Jason’s withdrawal. They must learn new patterns of interaction and communication. Since Jim drank excessively for a number of years, the shift from a “wet” to a “dry” state is extremely stressful. The therapist expects this transition to be difficult and again uses a psychoeducational framework to help them understand the nature of these changes.

Susan’s adjustment appears to be the most difficult. She expresses a sense of unfamiliarity with Jim and discomfort with his new behavior. Toward the end of his treatment program, she begins to express anger toward him for now being the “perfect father,” despite years of being emotionally absent. Although pleased that the family is growing closer, she feels that an unfair burden has been placed on her to prepare meals and provide emotional support while Jim “has fun” with the children or is self-absorbed in his recovery. Susan reveals that she has not been attending Al-Anon meetings or reading about codependency. The therapist indicates that, although Susan and Jason do not have a drinking problem, they must also work on their recovery.

The therapist now concentrates on non-alcohol-specific areas of family functioning. Susan’s concerns have touched on core problems of intimacy in the couple’s relationship. To reinforce an appropriate boundary between the parental and child subsystems, the therapist requests a meeting with Susan and Jim alone. (Although marital therapy seems indicated in this case, this change in format is not always necessary.) The goal of this marital therapy is to assist them in sharing their feelings and to solving problems through the use of traditional marital therapy techniques. An early task is to set guidelines for fair fighting as they express mutual feelings of bitterness and regret. The disorganization in the relationship is punctuated by joint statements regarding the possibility of divorce; yet, both partners indicate their commitment to each other and their desire to improve the marriage. After several conflictual sessions, the therapist is effective in helping each partner take responsibility for his or her contribution to the breakdown of their marriage and to work toward conflict resolution.

The prospect of divorce is unsettling to both of them. This crisis unveils deep fears in Susan stemming from her parents’ divorce, and she gains insight into the origins of her codependency. She realizes that she assumed a child-like position in the marriage, such as giving Jim full authority over financial matters and not monitoring her children’s activities. This appears to be the source of many of her complaints about changes in the family (i.e., being forced into a more mature role). She held the irrational belief that being more assertive and independent would cause him to leave her. For his part, Jim acknowledges that he encouraged her dependence, since this was the model he observed in his family of origin. However, this same upbringing left him with strong unmet emotional needs and weak coping skills. Therefore, he was equally dependent on Susan and fearful of abandonment by her. He was overwhelmed by his perceived sole responsibility for the financial well-being of the family. Rather than turn to his wife for assistance, alcohol became a way of coping with his fears. Once they identified these feelings, they were able to view each other’s behavior in a more positive light and to build trust in their relationship.

The therapist met with Jim and Susan for six weeks. Jim completed his eight-week treatment, participates in the weekly follow-up program, and has been sober for over three months. Emily continues to attend follow-up sessions at her treatment program and has been sober for almost six months. As Jim and Susan address their marital problems directly and change their relational patterns, the family enters stage four: family reorganization. The goal of this stage is to help the family in their reorganization through traditional family therapy, since their basic patterns of functioning have significantly changed. (If Jim had maintained sobriety but their interactional patterns had gone unchanged, the goal would have been family stabilization.)

A new stability in the marriage leads to overall improved functioning in the family. They remain in family therapy for two more months. As Susan and Jim continue to work on achieving mutuality in their relationship, their parenting improves. They make joint decisions regarding the children and feel more comfortable in asserting their authority. Thus, rules and expectations become clearer, and as a result, Emily and Jason show more age-appropriate behavior. Jason begins to explore an unexpressed artistic ability. In the past, Jim had tried to push him into athletic pursuits, for which he was not temperamentally suited. Although problems still arise, they offer opportunities for the family to build and practice new skills for problem solving and conflict resolution. The family interacts more and eats together on a regular basis, with Jim sharing parental responsibility with Susan. They show more effective communication, particularly pertaining to emotional expression. All family members attend support groups to address their individual needs. Jim and Susan jointly sought advice for addressing their financial problems and are implementing a plan.

Breaking old patterns and consolidating new ones is a trial and error process that transpires over the course of therapy. Yet this process will continue even after therapy is completed. One of the last issues discussed is Emily’s impending graduation and her plans to attend college in the fall. She wants to begin working this summer so she can save her money and offset some of the expenses, since the family’s financial situation remains uncertain. Jim’s business has shown slow improvement since he quit drinking, and Susan is considering part-time employment.

At the final session, while reviewing treatment gains and looking forward to the future, the family seems to realize that the end of therapy is really a beginning. Jim voices their commitment to break the cycle of alcoholism and codependence in their family. From Emily’s attempt at death, the family has begun a new life

CHAPTER 8 HISTORY OF DRUG USE AND DRUG LEGISLATION

British naval assault on a Chinese port during the first Opium War (1839–1842)

After reading this chapter, you will:

· ▸ Know the popular prejudices against racial and ethnic groups that determined drug policy

· ▸ Know the history of Prohibition

· ▸ Understand why policy toward opiates that did not change until 1914

· ▸ Know why cocaine never proved as popular as opiates until the 1960s

· ▸ Recognize how marijuana emerged as a symbol of nonconformity and eventually a political issue

· ▸ Know the history of the use of amphetamines

· ▸ Know the history of the use of barbiturates and tranquilizers

· ▸ Know the history of the use of hallucinogen

· ▸ Understand why drugs became a major political issue from the 1960s through the 1980s

· ▸ Appreciate why drugs as a political issue became dormant

The Drug War as Eugenics

Erik Roskes ( 2012 ), a forensic psychiatrist, refers to the “War on Drugs” as eugenics: the practice of ridding the human species of unfit biological stock, largely through sterilization. This was a popular practice in the United States well into the twentieth century. In North Carolina, for example, between 1929 and 1974 more than 7,600 persons were sterilized. Dr. Roskes refers to the drug war as eugenics without surgery: the mass incarceration for drug-related offenses of persons who disproportionately come from segments of society that suffer various, often multiple, deprivations: social deprivation, educational deprivation, nutritional deprivation, cultural deprivation, cognitive deprivation.

“  “There was little interest [at the end of the 19th century] in suppressing a business that was so profitable for opium merchants, shippers, bankers, insurance agencies and governments. Many national economies were as dependent on opium as the addicts themselves. Indeed, what Karl Marx described as ‘the free trade in poison' was such an important source of revenue for Great Powers that they fought for control of opium markets.”

—Antonio Maria Costa ( 2009 , 3)

The history of drug use and attempts at its control provides insight into the complexity of more contemporary control, enforcement, and social issues on this subject. As with many attempts at historical analyses, we are handicapped by the lack of adequate data on a number of items, particularly the extent of drug use at earlier periods in our history and of alcohol use during Prohibition. Providing an empirically based analysis of changing policies with respect to drugs is difficult without the ability to measure the effect of these changes, and, in fact, we cannot provide such measurements.

   Policy decisions, as we shall see in this chapter, have frequently been based on perceptions, beliefs, and attitudes with little empirical foundation. They have often reflected popular prejudices against a variety of racial and ethnic groups. 1  Indeed, race, religion, and ethnicity have been closely identified with the reaction to drugs in the United States: the Irish and alcohol; the Chinese and opium; African-Americans and cocaine; Mexicans and marijuana. “What we think about addiction very much depends on who is addicted” ( Courtwright 1982 , 3). And sometimes policy has reflected concern over issues of international, rather than domestic, politics. Because the earliest drug prohibitions in the United States reflected a concern with alcohol, we begin our examination with a history of that substance.

Alcohol and the Temperance Movement

Drinking alcoholic beverages for recreational purposes has an ancient history, with records of such use dating back more than 5,000 years. The Bible records that Noah planted a vineyard and drank of the wine “and was drunken” (Genesis 9, 21). Later we are told that the daughters of Lot made their father drunk with wine to trick him into propagating the family line (Genesis 19, 32–36). This unseemly use of alcohol could certainly serve as an object lesson against its use, but the practice of drinking alcoholic beverages appears near universal.

   The citizens of the United States have traditionally consumed large quantities of alcohol. “Early Americans drank alcohol at home and at work, and alcohol was ever-present in colonial social life” ( W. L. White 1998 , 1). When he retired from politics, George Washington started a whiskey business. In 1785, Dr. Benjamin Rush, the Surgeon General of the Continental Army and a signer of the Declaration of Independence, authored a pamphlet decrying the use of high-proof alcohol, which he claimed caused, among other maladies, moral degeneration, poverty, and crime. This helped to fuel the move toward prohibition and inspired the establishment in 1808 of the Union Temperance Society, the first of many such organizations ( Musto 1998 ). The Society was superseded by the American Temperance Union in 1836, and the work of the Union was supported by Protestant churches throughout the country. But the movement was divided over appropriate goals and strategies: Should moderation be preached, or should abstinence be forced through prohibition? “Between 1825 and 1850, the tide turned toward abstinence as a goal and legal alcohol prohibition as the means” ( W. L. White 1998 , 5).

   The abstinence view differs from the modern alcoholism movement in that it maintained that alcohol is inevitably dangerous for everyone: “Some people might believe they can drink moderately, but it is only a matter of time before they encounter increasing problems and completely lose control of their drinking.” Thus, “as strange as it seems to us today, the temperance message thus was that alcohol is inevitably addicting, in the same way that we now think of narcotics” ( Peele 1995 , 37).

   Opposition to alcohol was often intertwined with nativism, and efforts against alcohol and other psychoactive drugs were often a thinly veiled reaction to minority groups. (The early temperance movement, however, was strongly abolitionist.) Prohibitionists were typically rural, white Protestants antagonistic to urban Roman Catholics, particularly the Irish, who used the social world of the saloon to gain political power in large cities such as New York and Chicago ( Abadinsky 2013 ).

   The temperance movement made great progress everywhere in the country, and it often coincided with the anti-immigrant sentiment that swept over the United States during the 1840s and early 1850s. In 1843, this led to the formation in New York of the American Republican Party, which spread nationally as the Native American Party, or the “Know-Nothings.” (Many clubs were secret, and when outsiders inquired about the group, they were met with the response “I know nothing.”) Allied with a faction of the Whig Party, the Know-Nothings almost captured New York in 1854, and they did succeed in carrying Delaware and Massachusetts. They also won important victories in Pennsylvania, Rhode Island, New Hampshire, Connecticut, Maryland, Kentucky, and California. In 1855, the city of Chicago elected a Know Nothing mayor; and prohibition legislation was enacted in the Illinois legislature only to be was defeated in a public referendum that same year ( Asbury 1950 ). That same year about a third of the United States had prohibition laws, and other states debated their enactment ( Musto 1998 ). Slavery and abolition and the ensuing Civil War subsequently took the place of temperance as the day's most pressing issue ( Buchanan 1992 ).

   In 1869, the Prohibition Party attempted, with only limited success, to make alcohol a national issue. In 1874, the Women's Christian Temperance Union was established. Issues of temperance and nativism arose again strongly during the 1880s, leading to the formation of the American Protective Association, a rural-based organization that was strongly anti-Catholic and anti-Semitic. In 1893, the Anti-Saloon League was organized.

   Around the turn of the century, these groups moved from efforts to change individual behavior to a campaign for national prohibition. After a period of dormancy, the prohibition movement was revived in the years 1907 to 1919 ( Humphries and Greenberg 1981 ). By 1910, the Anti-Saloon League had become one of the most effective political action groups in U.S. history; it had mobilized Protestant churches behind a single purpose: to enact national prohibition ( Tindall 1988 ). In 1915, nativism and prohibitionism fueled the rise of the Ku Klux Klan, and this time the KKK spread into Northern states and exerted a great deal of political influence. During World War I, an additional element, anti-German xenophobia, was added because brewing and distilling were associated with German immigrants ( Cashman 1981 ).

   Big business was also interested in prohibition. Alcohol contributed to industrial inefficiency, labor strife, and the saloon, which served the interests of urban machine politics:

· Around 1908, just as the Anti-Saloon League was preparing for a broad state-by-state drive toward national prohibition, a number of businessmen contributed the funds essential for an effective campaign. The series of quick successes that followed coincided with an equally impressive number of wealthy converts, so that as the movement entered its final stage after 1913, it employed not only ample financing but a sudden urban respectability as well. Substantial citizens now spoke about a new discipline with the disappearance of the saloon and the rampaging drunk. Significantly, prominent Southerners with one eye to the Negro and another to the poorer whites were using exactly the same arguments. (Wiebe 1967, 290–291)

   Workmen's compensation laws also helped to stimulate business support for temperance. Between 1911 and 1920, forty-one states had enacted workmen's compensation laws, and Sean Cashman ( 1981 ) points out: “By making employers compensate workers for industrial accidents the law obligated them to campaign for safety through sobriety. In 1914, the National Safety Council adopted a resolution condemning alcohol as a cause of industrial accidents” (6).

National Prohibition

Acrimony between rural and urban America, between Protestants and Catholics, between Republicans and (nonsouthern) Democrats, between “native” Americans and more recent immigrants, and between business and labor reached a pinnacle with the 1919 ratification of the Eighteenth Amendment, which outlawed the manufacture and sale of alcoholic beverages in the United States— Prohibition  became federal law. According to Chambliss ( 1973 ), prohibition was accomplished by the political efforts of an economically declining segment of the American middle class: “By effort and some good luck this class was able to impose its will on the majority of the population through rather dramatic changes in the law” (10). Andrew Sinclair ( 1962 ) notes “national prohibition was a measure passed by village America against urban America” (163). We could add that it was also passed by much of Protestant America against Catholic (and, to a lesser extent, Jewish) America ( Sinclair 1962 ;  Gusfield 1963 ): “Thousands of Protestant churches held thanksgiving prayer meetings. To many of the people who attended, prohibition represented the triumph of America's towns and rural districts over the sinful cities” ( Coffey 1975 , 7). Mississippi was the first state to ratify Prohibition.

   The Eighteenth Amendment to the Constitution was ratified by the thirty-sixth state, Nebraska, on January 16, 1919. According to its own terms, the amendment became effective on January 16, 1920. Ten months after ratification, over a veto by President Woodrow Wilson, Congress passed the National Prohibition Act, usually referred to as the  Volstead Act  after its sponsor, Congressman Andrew Volstead of Minnesota. The Volstead Act strengthened the language of the amendment and defined as intoxicating all beverages containing more than 0.5 percent alcohol; it also provided for federal enforcement. Thus, the Prohibition Bureau, an arm of the Treasury Department, was created, soon becoming notorious for employing agents on the basis of political patronage.

   In addition to being inept and corrupt, bureau agents were a public menace. By 1930, 86 federal agents and 200 civilians had been killed, many of them innocent women and children. Prohibition agents set up illegal roadblocks and searched cars; drivers who protested were in danger of being shot. Agents who killed innocent civilians were rarely brought to justice; when they were indicted by local grand juries, the cases were simply transferred, and the agents escaped punishment ( Woodiwiss 1988 ). The bureau was viewed as a training school for bootleggers because agents frequently left the service to join their wealthy adversaries.

   The response of a large segment of the American population also proved to be a problem. People do not necessarily acquiesce to new criminal prohibitions, and general resistance can be fatal to the new norm ( Packer 1968 ). Moreover, primary resistance or opposition to a new law such as Prohibition can result, secondarily, in disregard for laws in general—negative contagion. During Prohibition, notes Sinclair ( 1962 ), a “general tolerance of the bootlegger and a disrespect for federal law were translated into a widespread contempt for the process and duties of democracy” (292). This was exemplified by the general lawlessness that reigned in Chicago:

· Banks all over Chicago were robbed in broad daylight by bandits who scorned to wear masks. Desk sergeants at police stations grew weary of recording holdups—from one hundred to two hundred were reported every night. Burglars marked out sections of the city as their own and embarked upon a course of systematic plundering, going from house to house night after night without hindrance…. Payroll robberies were a weekly occurrence and necessitated the introduction of armored cars and armed guards for the delivery of money from banks to business houses. Automobiles were stolen by the thousands. Motorists were forced to the curbs on busy streets and boldly robbed. Women who displayed jewelry in nightclubs or at the theater were followed and held up. Wealthy women seldom left their homes unless accompanied by armed escorts. ( Asbury 1950 , 339)

   The murder rate in the United States went from 6.8 per 100,000 persons in 1920 to 9.7 in 1933, the year Prohibition was repealed ( Chapman 1991c ), after which it began to decline. And while the United States had local organized crime before Prohibition, there were no large crime syndicates ( King 1969 ). Pre-Prohibition crime, insofar as it was organized, centered on corrupt political machines, vice entrepreneurs, and, at the bottom, gangs. The “Great Experiment” of Prohibition provided an opportunity for organized crime, especially violent forms, to blossom into an important force. Prohibition acted as a catalyst for the mobilization of criminal elements in an unprecedented manner, unleashing a heightened level of competitive violence and reversing the order between the criminal gangs and the politicians. It also led to an unparalleled level of criminal organization ( Abadinsky 2013 ). In 1933, when the repeal of Prohibition left a critical void in their business portfolios, criminal organizations turned to the drug trade.

Opium: A Long History

In addition to alcohol, the earliest “war against drugs” in the United States was its response to opium. Opium is the gum from the partially ripe seedpod of the opium poppy. There is no agreement on where the plant originated, and a great deal of debate surrounds its earliest use as a drug, which might date back to the Stone Age. The young leaves of the plant have been used as an herb for cooking and as a salad vegetable, and its small, oily seeds, which are high in nutritional value, can be eaten, pressed to make an edible oil, baked into poppy seed cakes, ground into poppy flour, or used as lamp oil. As a vegetable fat source “the seed oil could have been a major factor attracting early human groups to the opium poppy” ( Merlin 1984 , 89). Archaeologists have discovered ancient art relics that may depict opium use in Egyptian religious rituals as early as 3500 BCE ( Inverarity, Lauderdale, and Field 1983 ). By 1500 BCE, the Egyptians had definitely discovered the medical uses of opium: It is listed as a pain reliever in the Ebers Papyrus ( Burkholz 1987 ). From Egypt its use spread to Greece ( R. O'Brien and Cohen 1984 ). Opium is discussed in Homer's works, the Iliad and the Odyssey (circa 700 BCE), and the term opium is derived from the Greek word opion, meaning the juice of the poppy ( Bresler 1980 ). Hippocrates (460–357 BCE), the “father of medicine,” recommended drinking the juice of the white poppy mixed with the seed of the nettle.

   Opium was used by doctors in classical Greece and ancient Rome, and Arab traders brought it to China for use in medicine. Later, the Crusaders picked it up from Arab physicians and brought it back to Europe where it became a standard medicine. Opium is mentioned by Shakespeare in Othello and by Chaucer, Sir Thomas Browne, and Robert Burton. In the early sixteenth century, the physician Paracelsus made a tincture of opium—powdered opium dissolved in alcohol—that he called laudanum, a popular medication until the end of the nineteenth century ( R. O'Brien and Cohen 1984 ).

   Two centuries ago, opium was generally available as a cure for everything. It was used much like aspirin; every household had some, usually in the form of laudanum. Naturally, the general availability of opium and the medical profession's enthusiasm for it helped to create addicts, some of them very famous, such as the poet Samuel Taylor Coleridge (1772–1834) and the essayist Thomas De Quincy (1785–1859), who wrote Confessions of an English Opium-Eater ( 1821 ). At the time medicine was primitive, doctors had no concept of addiction, and opium became the essential ingredient of innumerable remedies dispensed in Europe and America for the treatment of diarrhea, dysentery, asthma, rheumatism, diabetes, malaria, cholera, fevers, bronchitis, insomnia, and pain of any kind ( Fay 1975 ). There was nothing to alert patients to the dangers of the patent medicines they were prescribed or to prepare them for the side effects. As a result, no more stigma was attached to the opium habit than to alcoholism; it was an unfortunate weakness, not a vice. Wherever it was known, opium use was both medicinal and recreational ( Alvarez 2001 ).

   In explaining the popularity of opium, Terry and Pellens ( 1928 ) state: “When we realize that the chief end of medicine up to the beginning of the [nineteenth] century was to relieve pain, that therapeutic agents were directed at symptoms rather than cause, it is not difficult to understand the wide popularity of a drug which either singly or combined so eminently was suited to the needs of so many medical situations” (58).

   Opium is a labor-intensive product. To produce an appreciable quantity requires repeated incisions of a great number of poppy capsules: about 18,000 capsules—one acre—to yield twenty pounds of opium ( Fay 1975 ). Accordingly, supplies of opium were rather limited in Europe until the eighteenth century, when improvements in plantation farming increased opium production. Attempts to produce domestic opium in the United States were not successful. While the poppy could be grown in many sections of the United States, particularly the South, Southwest, and California, labor costs and an opium gum that proved low in potency led to a reliance on imported opium ( H. W. Morgan 1981 ).

   As the primary ingredient in many “patent medicines” (actually secret formulas that carried no patent at all) opiates were readily available in the United States until 1914, and quacks prescribed and promoted them for general symptoms as well as for specific diseases. People who were not really ill were frightened into the patent medicine habit ( Young 1961 ). Patients who were actually sick received the false impression that they were on the road to recovery. Of course, because there was often little or no scientific medical treatment for even the mildest of diseases, a feeling of well-being was at least psychologically, and perhaps by extension physiologically, beneficial. However, babies born to opiate-using mothers were often small and experienced the distress of withdrawal. Harried mothers often responded by relieving them with infant remedies that contained opium.

The first significant piece of prohibitionary drug legislation in the United States was enacted by the city of San Francisco in 1875; the ordinance prohibited the operation of opium dens, commercial establishments for the smoking of opium.

   The smoking of opium was popularized by Chinese immigrants, who brought the habit with them to the United States. During the latter part of the nineteenth and early twentieth centuries they also operated commercial opium dens that often attracted the attention of the police, “not because of the use of narcotics but because they became gathering places for thieves, footpads [highwaymen] and gangsters.” In fact, “opium dens were regarded as in a class with saloons and, for many years, were no more illegal” ( Katcher 1959 , 287).

Morphine and Heroin

At the end of the eighteenth century ( Latimer and Goldberg 1981 ) or early in the nineteenth ( Bresler 1980 ;  Nelson et al. 1982 ;  Merlin 1984 ;  Musto 1987 ), a German pharmacist poured liquid ammonia over opium and obtained an alkaloid, a white powder that he found to be many times more powerful than opium. Friedrich W. Serturner named the substance morphium after Morpheus, the Greek god of sleep and dreams; ten parts of opium can be refined into one part of morphine ( Bresler 1980 ). It was not until 1817, however, that articles published in scientific journals popularized the new drug, resulting in widespread use by doctors. Quite incorrectly, as it turned out, the medical profession viewed morphine as an opiate without negative side effects.

   By the 1850s, morphine tablets and a variety of morphine products were readily available without prescription. In 1856, the hypodermic method of injecting morphine directly into the bloodstream was introduced to U.S. medicine. The popularity of morphine rose during the Civil War, when the intravenous use of the drug to treat battlefield casualties was rather indiscriminate ( Terry and Pellens 1928 ). Following the war, morphine use among ex-soldiers was so common as to give rise to the term army disease. Nevertheless, “Medical journals were replete with glowing descriptions of the effectiveness of the drug during wartime and its obvious advantages for peacetime medical practice” ( Cloyd 1982 , 21). Hypodermic kits became widely available, and the use of unsterile needles by many doctors and laypersons led to abscesses or disease ( H. W. Morgan 1981 ).

   In the 1870s, morphine was exceedingly cheap, cheaper than alcohol, and pharmacies and general stores carried preparations that appealed to a wide segment of the population, whatever the individual emotional quirk or physical ailment. Anyone who visited nearly any physician for any complaint, from a toothache to consumption, would be prescribed morphine ( Latimer and Goldberg 1981 ), and the substance was widely used by physicians themselves. Morphine use in the latter part of the nineteenth century was apparently widespread in rural America ( Terry and Pellens 1928 ).

   Starting in the 1870s, doctors injected women with morphine to numb the pain of “female troubles” or to turn the “willful hysteric” into a manageable invalid. By the 1890s, when the first drug epidemic peaked, female medical addicts reportedly made up almost half of all addicts in the United States. In the twentieth century the drug scene shifted to underworld elements of urban America, the disreputable “sporting class”: prostitutes, pimps, thieves, gamblers, gangsters, entertainers, active homosexuals, and youths who admired the sporting men and women ( Stearns 1998 ).

   In 1874, a British chemist experimenting with morphine synthesized diacetylmorphine, and the most powerful of opiates came into being: “Commercial promotion of the new drug had to wait until 1898 when the highly respected German pharmaceutical combine Bayer, in perfectly good faith but perhaps without sufficient prior care, launched upon an unsuspecting world public this new substance, for which they coined the trade name ‘heroin’ and which they marketed as—of all things—a ‘sedative for coughs’” ( Bresler 1980 , 11). Jack Nelson and his colleagues ( 1982 ) state that heroin was actually isolated in 1898 in Germany by Heinrich Dreser, who was searching for a nonhabit- forming pain reliever to take the place of morphine. Dreser reportedly named it after the German word for hero, heroisch. Opiates, including morphine and heroin, were readily available in the United States until 1914. In 1900, 628,177 pounds of opiates were imported into the United States ( Bonnie and Whitebread 1970 ). The President's Commission on Organized Crime (PCOC) ( 1986 ) notes that between the Civil War and 1914 there was a substantial increase in the number of people using opiates. This was the consequence of a number of factors:

· ▸ The spread of opium smoking from Chinese immigrants into the wider community

· ▸ An increase in morphine addiction as a result of its indiscriminate use to treat battlefield casualties during the Civil War

· ▸ The widespread administration of morphine by hypodermic syringe

· ▸ The widespread use of opium derivatives by the U.S. patent medicine industry

· ▸ Beginning in 1898, the marketing of heroin as a safe, powerful, and nonaddictive substitute for the opium derivatives morphine and codeine

China and the Opium Wars

Until the sixteenth century, China was a military power whose naval fleet surpassed any that the world had ever known. A fifteenth-century power struggle ultimately led to a regime dominated by Confucian scholars; in 1525, they ordered the destruction of all oceangoing ships and set China on a course that would lead to poverty, defeat, and decline ( Kristoff 1999 ).

   In 1626 a British warship appeared off the coast of China, and its captain imposed his will on Canton (now Guangzhou) with a bombardment. In response to the danger posed by British ships the emperor of China opened the city of Canton to trade, and Britain granted the British East India Company a monopoly over the China trade. Particularly important to this trade was the shipping of tea to England. By the 1820s, the trade situation between England and China paralleled trade between the United States and Japan. Although British consumers had an insatiable appetite for Chinese tea, the Chinese desired few English goods. The British attempted to introduce alcohol, but a large percentage of Asians have enzyme systems that make drinking alcohol extremely unpleasant. Opium was different ( Beeching 1975 ). Poppy cultivation was an important source of revenue for the Mughal emperors (Muslim rulers of India between 1526 and 1857). When the Mughal Empire fell apart, the British East India Company salvaged and improved the system of state control of opium. In addition to the domestic market, the British supplied Indian opium to China.

   Opium was first prohibited by the Chinese government in Peking (Beijing) in 1729, when only small amounts of the substance were reaching China. Ninety years earlier, tobacco had been similarly banned as a pernicious foreign article. Opium use was strongly condemned in China as a violation of Confucian principles, and for many years the imperial decree against opium was generally supported by the population ( Beeching 1975 ). In 1782, a British merchant ship's attempt to sell 1,601 chests of opium in China resulted in a total loss, as no purchasers could be found. By 1799, however, a growing traffic in opium led to an imperial decree condemning the trade. Latimer and Goldberg ( 1981 ) doubt that opium addiction was extensive or particularly harmful to China as a whole. The poorer classes, the authors note, could afford only adulterated opium, which was unlikely to produce addiction. “Just why the Chinese chose to obtain their supplies from India,” states Peter Fay ( 1975 , 11–12), “is no clearer than why, having obtained it, they smoked it instead of ate it.” In the end, he notes, the Chinese came to prefer the Indian product to their own. However, because the preference was to smoke opium, it had to be specially prepared by being boiled in water, filtered, and boiled again until it reached the consistency of molasses, thereby becoming “smoking opium.”

   Like the ban on tobacco, the one on opium was not successful (official corruption was endemic in China). As consumption of imported opium increased and the method of ingestion shifted from eating to smoking, official declarations against opium increased, and so did smuggling. “When opium left Calcutta, stored in the holds of country ships and consigned to agents in Canton, it was an entirely legitimate article. It remained an entirely legitimate article all the way up to the China Sea. But the instant it reached the coast of China, it became something different. It became contraband” ( Fay 1975 , 45). In fact, the actual shipping of opium to China was accomplished by independent British or Parsee merchants. Thus, notes Beeching ( 1975 ), “the Honourable East India Company was able to wash its hands of all formal responsibility for the illegal drug trade” (26).

   Opium furnished the British with the silver needed to buy tea. Because opium was illegal in China, however, its importation—smuggling—brought China no tariff revenue. Before 1830, opium was transported to the coast of China, where it was offloaded and smuggled by the Chinese themselves. The outlawing of opium by the Chinese government led to the development of an organized underworld; gangs became secret societies—triads—that still move heroin out of the Far East to destinations all over the world ( Latimer and Goldberg 1981 ) (discussed in  Chapter 9 ). The armed opium ships were safe from Chinese government intervention, and the British were able to remain aloof from the smuggling itself.

   In the 1830s, the shippers grew bolder and entered Chinese territorial waters with their opium cargo. The British East India Company, now in competition with other opium merchants, sought to flood China with cheap opium and drive out the competition ( Beeching 1975 ). In 1837, the emperor ordered his officials to move against opium smugglers, but the campaign was a failure, and the smugglers grew even bolder. The following year the emperor changed his strategy and moved against Chinese traffickers and drug users, as only a total despot could do, helping to dry up the market for opium. As a result, the price fell significantly ( Hanes and Sanello 2005 ).

The First Opium War.   In 1839, in dramatic fashion, Chinese authorities laid siege to the port city of Canton, confiscating and destroying all opium awaiting offloading from foreign ships. The merchantmen agreed to stop importing opium into China, and the siege was lifted. The British merchants petitioned their own government for compensation and retribution. The reigning Parliamentary Whig majority was very weak, however, and compensating the opium merchants was not politically or financially feasible. Instead, the cabinet, without Parliamentary approval, decided on a war that would result in the seizure of Chinese property ( Fay 1975 ).

   In 1840, a British expedition attacked the poorly armed and poorly organized Chinese forces. In the rout that followed, the Chinese emperor was forced to pay $6 million for the opium his officials had seized and $12 million as compensation for the war. Hong Kong became a Crown colony, and the ports of Canton, Amoy (Xiamen), Foochow (Fuzhou), Ningpo, and Shanghai were opened to British trade. Opium was not mentioned in the peace (surrender) treaty, but the trade resumed with new vigor. In a remarkable reversal of the balance of trade, by the mid-1840s China had an opium debt of about 2 million pounds sterling ( Latimer and Goldberg 1981 ). In the wake of the First Opium War, China was laid open to extensive missionary efforts by Protestant evangelicals, who, although they opposed the opium trade, viewed saving souls as their primary goal. Christianity, they believed, would save China from opium ( Fay 1975 ). Unfortunately, morphine was actively promoted by Catholic and Protestant missionaries as an agent for detoxifying opium addicts ( Latimer and Goldberg 1981 ).

Second Opium War.   The Second Opium War began in 1856, when the balance of payments once again favored China. In that year a minor incident between the British and Chinese governments was used as an excuse to force China into making further treaty concessions. This time the foreign powers seeking to exploit a militarily weak China included Russia, the United States, and particularly France which was jealous of the British success. Canton was sacked, and a combined fleet of British and French warships sailed right up the Grand Canal to Peking and proceeded to sack and burn the imperial summer palace, a complex of 200 buildings spread over eighty square miles of carefully landscaped parkland with extensive libraries and priceless works of art ( Hanes and Sanello 2005 ).

   The emperor was forced to indemnify the British 20,000 pounds sterling, more than enough to offset the balance of trade which was the real cause of the war. A commission was appointed to legalize and regulate the opium trade ( Latimer and Goldberg 1981 ) that increased from less than 59,000 chests a year in 1860 to more than 105,000 by 1880 ( Beeching 1975 ). Until 1946 the British permitted the use of opiates in its Crown colony of Hong Kong, first under an official monopoly and, after 1913, directly by the government ( Lamour and Lamberti 1974 ). During Japan's occupation of China, which began a few years before its attack on Pearl Harbor, large amounts of heroin were trafficked by the Japanese army's “special services branch,” which helped to finance the cost of the occupation ( Karch 1998 ).

The Chinese Problem and the American Response

Chinese laborers were originally brought into the United States after 1848 to work in the gold fields, particularly in those aspects of mining that were most dangerous because few white men were willing to engage in blasting shafts, placing beams, and laying track lines in the gold mines. Chinese immigrants also helped to build the Western railroad lines at pay few whites would accept—known as “coolie wages.” After their work was completed, the Chinese were often banned from the rural counties; by the 1860s they were clustering in cities on the Pacific coast, where they established Chinatowns—and where many of them smoked opium.

   The British opium monopoly in China was challenged in the 1870s by opium imported from Persia and cultivated in China itself. In response, British colonial authorities, heavily dependent on a profitable opium trade, increased the output of Indian opium, causing a price decline that was aimed at driving the competition out of business. The resulting oversupply increased the amount of opium entering the United States for the Chinese population.

   Beginning in 1875, there was an economic depression in California. As a result, the first significant piece of prohibitionary drug legislation in the United States was enacted by the city of San Francisco. “The primary event that precipitated the campaign against the Chinese and against opium was the sudden onset of economic depression, high unemployment levels, and the disintegration of working-class standards of living” ( Helmer 1975 , 32). The San Francisco ordinance prohibited the operation of opium dens, commercial establishments for the smoking of opium, “not because of health concerns as such, but because it was believed that the drug stimulated coolies into working harder than non-smoking whites” ( Latimer and Goldberg 1981 , 208). Throughout the latter part of the nineteenth century, Chinese Americans were demonized, particularly in the West ( Pfaelzer 2007 ).

   Depressed economic conditions and xenophobia led one Western state after another to follow San Francisco's lead and enact anti-Chinese legislation that often included prohibiting the smoking of opium. The anti-Chinese nature of the legislation was noted in some early court decisions. In 1886, an Oregon district court, responding to a petition for habeas corpus filed by Yung Jon, who had been convicted of opium violations, stated: “Smoking opium is not our vice, and therefore it may be that this legislation proceeds more from a desire to vex and annoy the ‘Heathen Chinese’ in this respect, than to protect the people from the evil habit. But the motives of legislators cannot be the subject of judicial investigation for the purpose of affecting the validity of their acts” ( Bonnie and Whitebread 1970 , 997).

   “After 1870 a new type of addict began to emerge, the white opium smoker drawn primarily from the underworld of pimps and prostitutes, gamblers, and thieves” ( Courtwright 1982 , 64). During the 1890s Chicago's Chinatown was located in the notorious First Ward, whose politicians grew powerful and wealthy by protecting almost every vice known to humanity. But First Ward alderman John “Bathhouse” Coughlin “couldn't stomach” opium smokers and threatened to raid the dens himself if necessary. There was constant police harassment, and in 1894 the city enacted an antiopium ordinance. By 1895, the last of the dens had been raided out of business ( Sawyers 1988 ).

   Anti-Chinese efforts were supported and advanced by Samuel Gompers (1850–1924) as part of his effort to establish the American Federation of Labor. The Chinese served as scapegoats for organized labor that depicted the “yellow devils” as undercutting wages and breaking strikes. Anti-opium legislation was also fostered by stories of white women being seduced by Chinese white slavers through the use of opium. 2  In 1882, the Chinese Exclusion Act banned the entry of Chinese laborers into the United States. (It was not until 1943, when the United States was allied with China in a war against Japan, that citizenship rights were extended to Chinese immigrants, and China was then permitted an annual immigration of 105 individuals.)

   In 1883, Congress raised the tariff on the importation of smoking opium. In 1887, apparently in response to obligations imposed on the United States by a Chinese-American commercial treaty negotiated in 1880 and becoming effective in 1887, Congress banned the importation of smoking opium by Chinese subjects. Americans, however, were still permitted to import the substance, and many did so, selling it to both Chinese and American citizens ( PCOC 1986 ). The Tariff Act of 1890 increased the tariff rate on smoking opium to $12 per pound, resulting in a substantial increase in opium smuggling and the diversion of medicinal opium for manufacture into smoking opium. In response, in 1897 the tariff was reduced to $6 per pound ( PCOC 1986 ).

   During the nineteenth century, opiates were not associated with crime in the public mind. While some people may have frowned on opium use as immoral,

· employees were not fired for addiction. Wives did not divorce their addicted husbands or husbands their addicted wives. Children were not taken from their homes and lodged in foster homes or institutions because one or both parents were addicted. Addicts continued to participate fully in the life of the community. Addicted children and young people continued to go to school, Sunday School, and college. Thus, the nineteenth century avoided one of the most disastrous effects of current narcotics laws and attitudes: the rise of a deviant addict subculture, cut off from respectable society and without a road back to respectability. ( Brecher 1972 , 6–7)

The Pure Food and Drug Act

National efforts against opiates (and cocaine) were part of a larger campaign to regulate drugs and the contents of food substances; in 1879, a bill was introduced in Congress to accomplish national food and drug regulation. These efforts were opposed by the Proprietary Association of America, which represented the patent medicine industry. The medical profession was more interested in dealing with quacks within the profession than with quack medicines, and the American Pharmaceutical Association was of mixed mind: Its members, in addition to being scientists, were merchants who found the sale of proprietary remedies bulking large in their gross income ( J. H. Young 1961 ). Toward the end of the nineteenth century the campaign for drug regulation was assisted by agricultural chemists who decried the use of chemicals to defraud consumers into buying spoiled canned and packaged food. In 1884, state-employed chemists formed the Association of Official Agricultural Chemists to combat this widespread practice. They began to expand their efforts into nonfoodstuffs, including patent medicines.

   The nation's newspapers and magazines made a considerable amount of money from advertising patent medicines. Toward the turn of the century, however, a few periodicals, in particular Ladies Home Journaland Collier's, began vigorous investigations and denunciations of patent medicines. Eventually, the American Medical Association (AMA, founded in 1847), which was a rather weak organization at the close of the nineteenth century because the vast majority of doctors were not members ( Musto 1973 ), began to campaign in earnest for drug regulation.

   U.S. Senate hearings on the pure food issue gained a great deal of newspaper coverage and aroused the public ( J. H. Young 1961 ). The dramatic event that quickly led to the adoption of the Pure Food and Drug Act, however, was the 1906 publication of Upton Sinclair's The Jungle. Sinclair, in a novelistic description of the meat industry in Chicago, exposed the filthy, unsanitary, and unsafe conditions under which food reached the consumer. Sales of meat fell by almost 50 percent, and President Theodore Roosevelt dispatched two investigators to Chicago to check on Sinclair's charges. Their “report not only confirmed Sinclair's allegations, but added additional ones. Congress was forced by public opinion to consider a strong bill” ( Ihde 1982 , 42). The result was the Pure Food and Drug Act, passed later that same year, which required medicines to list certain drugs and their amounts, including alcohol and opiates.

China and the International Opium Conference

The international U.S. response to drugs in the twentieth century is directly related to trade with China. To increase influence in China and thus improve its trade position, the United States supported the International Reform Bureau (IRB), a temperance organization representing over thirty missionary societies in the Far East, which was seeking a ban on opiates. As a result, in 1901 Congress enacted the Native Races Act, which prohibited the sale of alcohol and opium to “aboriginal tribes and uncivilized races.” The provisions of the act were later expanded to include “uncivilized elements” in the United States proper: Indians, Eskimos, and Chinese ( Latimer and Goldberg 1981 ).

   As a result of the Spanish-American War in 1898, the Philippines were ceded to the United States. At the time of Spanish colonialism opium smoking was widespread among Chinese workers on the islands. Canadian-born Reverend Charles Henry Brent (1862–1929), a supporter of the IRB, arrived in the Philippines as the Episcopal bishop during a cholera epidemic that began in 1902 and that reportedly had led to an increase in the use of opium. As a result of his efforts, in 1905 Congress enacted a ban against sales of opium to Filipino natives except for medicinal purposes. Three years later the ban was extended to all residents of the Philippines. It appears that the legislation was ineffective, and smoking opium remained widely available ( Musto 1973 ). “Reformers attributed to drugs much of the appalling poverty, ignorance, and debilitation they encountered in the Orient. Opium was strongly identified with the problems afflicting an apparently moribund China. Eradication of drug use was part of America's white man's burden and a way to demonstrate the New World's superiority” ( H. W. Morgan 1974 , 32).

   Bishop Brent proposed the formation of an international opium commission to meet in Shanghai in 1909. This plan was supported by President Theodore Roosevelt, who saw it as a way of assuaging Chinese anger at the passage of the Chinese Exclusion Act ( Latimer and Goldberg 1981 ). The International Opium Commission, chaired by Brent and consisting of representatives from thirteen nations, convened in Shanghai on February 1. Brent was successful in rallying the conferees around the U.S. position that opium was evil and had no nonmedical use. The commission unanimously adopted a number of vague resolutions; the most important ( Terry and Pellens 1928) :

· 1. Each government to take action to suppress the smoking of opium at home and in overseas possessions and settlements

· 2. Opium has no use outside of medicine and, accordingly, that each country should move toward increasingly stringent regulations concerning opiates

· 3. Measures should be taken to prevent the exporting of opium and its derivatives to countries that prohibit its importation

   Only the United States and China, however, were eager for future conferences, and legislative efforts against opium following the conference were generally unsuccessful. Southerners were distrustful of federal enforcement, and the drug industry was opposed. Efforts to gain Southern support for antidrug legislation focused on the alleged use of cocaine by African Americans—the substance was reputed to make them uncontrollable. Although tariff legislation with respect to opium already existed, Terry and Pellens ( 1928 ) note that its purpose was to generate income. The first federal legislation to control the domestic use of opium was passed in 1909 as a result of the Shanghai conference. “An Act to prohibit the importation and use of opium for other than medicinal purposes” failed to regulate domestic opium production and manufacture, nor did it control the interstate shipment of opium products, which continued to be widely available through retail and mail order outlets ( PCOC 1986 ).

   A second conference was held in The Hague in 1912, with the United States, Turkey, Great Britain, France, Portugal, Japan, Russia, Italy, Germany, Persia, the Netherlands, and China in attendance. A number of problems stood in the way of an international agreement: Germany wished to protect her burgeoning pharmaceuticals industry and insisted on a unanimous vote before any action could be agreed upon; Portugal insisted on retaining the Macao opium trade; the Dutch demanded to maintain their opium trade in the West Indies; and Persia and Russia wanted to keep on growing opium poppies. Righteous U.S. appeals to the delegates were rebuffed with allusions to domestic usage and the lack of laws in the United States ( Latimer and Goldberg 1981 ). Nevertheless, the conference managed to put together a patchwork of agreements known as the International Opium Convention, which was ratified by Congress on October 18, 1913. The signatories committed themselves to enacting laws aimed at suppressing the use of opium, morphine, and cocaine as well as drugs prepared or derived from these substances ( PCOC 1986 ). On December 17, 1914, the Harrison Act, which represented this country's attempt to carry out the provisions of the Hague Convention, was approved by President Woodrow Wilson.

The Harrison Act

The Harrison Act provided that any person who was in the business of dealing in drugs covered by the act, including the opium derivatives morphine and heroin, as well as cocaine, was required to register annually and to pay a special annual tax of $1. The statute made it illegal to sell or give away opium or opium derivatives and coca or its derivatives without a written order on a form issued by the commissioner of revenue. People who were not registered were prohibited from engaging in interstate traffic in the drugs, and no one could possess any of the drugs who had not registered and paid the special tax, under a penalty of up to five years imprisonment and a fine of no more than $2000. Rules promulgated by the Treasury Department permitted only medical professionals to register, and they had to maintain records of the drugs they dispensed. Within the first year more than 200,000 medical professionals registered, and the small staff of Treasury agents could not scrutinize the number of prescription records that were generated ( Musto 1973 ).

   It was concern with federalism—constitutional limitation on the police powers of the central government—that led Congress to use the taxing authority of the federal government to control drugs. While few people today would question the Drug Enforcement Administration's right to register physicians and pharmacists and control what drugs they can prescribe and dispense, at the beginning of the twentieth century federal authority to regulate narcotics and the prescription practices of physicians was generally thought to be unconstitutional ( Musto 1998 ). In 1919, use of taxing authority to regulate drugs was upheld by the Supreme Court:

· If the legislation enacted has some reasonable relation to the exercise of the taxing authority conferred by the Constitution, it cannot be invalidated because of the supposed motives which induced it…. The Act may not be declared unconstitutional because its effect may be to accomplish another purpose as well as the raising of revenue. If the legislation is within the taxing authority of Congress—that is sufficient to sustain it. (United States v. Doremus 249 U.S. 86)

   The Harrison Act was enacted with the support of the AMA and the American Pharmaceutical Association, both of which had grown more powerful and influential in the first two decades of the twentieth century, since the medical profession had been granted a monopoly on dispensing opiates and cocaine. The Harrison Act also had the effect of imposing a stamp of illegitimacy on the use of most narcotics, fostering an image of the immoral and degenerate “dope fiend” ( Bonnie and Whitebread 1970 ). At this time, according to Courtwright's ( 1982 ) estimates, there were about 300,000 opiate addicts in the United States. But, he notes, the addict population was already changing. The medical profession had, by and large, abandoned its liberal use of opiates—imports of medicinal opiates declined dramatically during the first decade of the twentieth century—and the public mind, as well as that of much of the medical profession, came to associate heroin with urban vice and crime. In contrast with opiate addicts of the nineteenth century, opiate users of the twentieth century were increasingly male habitués of pool halls and bowling alleys, denizens of the underworld, and they typically used heroin ( Acker 2002 ;  Kinlock; Hanlon, and Nurco 1998 ). As in the case of minority groups, this marginal population was an easy target of drug laws and drug law enforcement.

Drug Prohibition

Drug laws reflect the decision of some persons that other persons who wish to consume certain substances should not be permitted to act on their preferences. Nor should anyone be permitted to satisfy the desires of drug consumers by making and selling the prohibited drug…. [The] most important characteristic of the legal approach to drug use is that these consumptive and commercial activities are being regulated by force.

Source:  Barnett 1987 , 73.

   The commissioner of the Internal Revenue Service (IRS) was placed in charge of upholding the Harrison Act, and in 1915, 162 collectors and agents of the Miscellaneous Division of the IRS were given the responsibility for enforcing drug laws. In 1919, the Narcotics Division was created within the Bureau of Prohibition with a staff of 170 agents and an appropriation of $270,000. The Narcotics Division, however, was tainted by its association with the notoriously inept and corrupt Prohibition Bureau and suffered from a corruption scandal of its own: “The public dissatisfaction intensified because of a scandal involving falsification of arrest records and charges relating to payoffs by, and collusion with, drug dealers” ( PCOC 1986 , 204). In response, in 1930 Congress removed drug enforcement from the Bureau of Prohibition and established the Federal Bureau of Narcotics (FBN) as a separate agency within the Department of the Treasury. “Although the FBN was primarily responsible for the enforcement of the Harrison Act and related drug laws, the task of preventing and interdicting the illegal importation and smuggling of drugs remained with the Bureau of Customs” ( PCOC 1986 , 205).

Case Law Results

In 1916, the Supreme Court ruled in favor of a physician (Dr. Moy) who had provided maintenance doses of morphine to an addict (United States v. Jin Fuey Moy 241 U.S. 394). In 1919, however, the Court ruled that a prescription for morphine issued to a habitual user not under a physician's care that was intended not to cure but to maintain the habit is not a prescription and thus violates the Harrison Act (Webb v. United States 249 U.S. 96). However, private physicians found it impossible to handle the large drug clientele that was suddenly created; they could do nothing “more than sign prescriptions” ( Duster 1970 , 16).

   In United States v. Behrman, the Court ruled that a physician was not entitled to prescribe large doses of proscribed drugs for self-administration even if the addict was under the physician's care, stating: “Prescriptions in the regular course of practice did not include the indiscriminate doling out of narcotics in such quantity as charged in the indictments” (United States v. Behrman 258 U.S. 280, 289, 1922). In 1925, the Court limited the application of Behrman when it found that a physician who had prescribed small doses of drugs for the relief of an addict did not violate the Harrison Act (Linder v. United States 268 U.S. 5). In reversing the physician's conviction, the Court distinguished between Linder and excesses shown in the case of Behrman:

· The enormous quantities of drugs ordered, considered in connection with the recipient's character, without explanation, seemed enough to show prohibited sales and to exclude the idea of bona fide professional activity. The opinion [in Behrman] cannot be accepted as authority for holding that a physician, who acts fide bona and according to fair medical standards, may never give an addict moderate amounts of drugs for self-administration in order to relieve conditions incident to addiction. Enforcement of the tax demands no such drastic rule, and if the Act had such scope it would certainly encounter grave constitutional guarantees.

   In fact, the powers of the Narcotics Division were clear and limited to the enforcement of registration and record-keeping regulations. “The large number of addicts who secured their drugs from physicians were excluded from the Division's jurisdiction. Furthermore, the public's attitude toward drug use,” notes Dickson ( 1977 ), “had not much changed with the passage of the Act—there was some opposition to drug use, some support of it, and a great many who did not care one way or the other. The Harrison Act was actually passed with very little publicity or news coverage” (39).

   Bonnie and Whitebread ( 1970 ) note the similarities between the temperance and antinarcotics movements: “Both were first directed against the evils of large scale use and only later against all use. Most of the rhetoric was the same: These euphoriants produced crime, pauperism and insanity.” However, “the temperance movement was a matter of vigorous public debate; the anti-narcotics movement was not. Temperance legislation was the product of a highly organized nationwide lobby; narcotics legislation was largely ad hoc. Temperance legislation was designed to eradicate known evils resulting from alcohol use; narcotics legislation was largely anticipatory” (976). In fact, notes Morgan ( 1981 ), comparisons between alcohol and opiates—until the nature of addiction became clear—were often favorable to opium. It was not public sentiment that led to antidrug legislation; nevertheless, the result of such legislation was an increasing public perception of the dangerousness of certain drugs ( Bonnie and Whitehead 1970 ). As we will see, this perception was fanned by officials of the federal drug enforcement agency.

Narcotic Clinics and Enforcement

Writing in 1916, Pearce Bailey ( 1974 , 173–174) noted that the passage of the Act “spread dismay among the heroin takers”:

· They saw in advance the increased difficulty and expense of obtaining heroin as a result of this law; then the drug stores shut down, and the purveyors who sell heroin on the street corners and in doorways became terrified, and for a time illicit trade in the drug almost ceased… . Once the law was established the traffic was resumed, but under very different circumstances. The price of heroin soared [900 percent, and was sold in adulterated form]. This put it beyond the easy reach of the majority of adherents, most of whom do not earn more than twelve or fourteen dollars a week. Being no longer able to procure it with any money that they could lay their hands on honestly, many were forced to apply for treatment for illness brought about by result of arrest for violation of the law.

   Beginning in 1918, narcotics clinics opened in almost every major city. Information about them is sketchy ( Duster 1970 ), and there is a great deal of controversy over their operations. While they were never very popular with the general public, most clinics were well run under medical supervision ( H. W. Morgan 1981 ). While some clinics were guilty of a variety of abuses, the good ones enabled addicts to continue their normal lives without being drawn into the black market in drugs ( Duster 1970 ). The troubled clinics, however, such as those in New York, where the number of patients overwhelmed the medical staff, generated a great deal of newspaper coverage, resulting in an outraged public.

   Following World War I and the Bolshevik Revolution in Russia, xenophobia and prohibitionism began to sweep the nation. The United States severely restricted immigration, and alcohol and drug use was increasingly associated with an alien population. In 1922, federal narcotics agents closed the drug clinics and began to arrest physicians and pharmacists who provided drugs for maintenance. At issue was Section 8 of the Harrison Act, which permitted the possession of controlled substances if prescribed “in good faith” by a registered physician, dentist, or veterinarian in accord with “professional practice.” The law did not define “good faith” or “professional practice.” Under a policy developed by the federal narcotics agency, thousands of people, including many physicians—more than 25,000 between 1914 and 1938 ( W. L. White 1998 )—were charged with violations: “Whether conviction followed or not mattered little as the effects of press publicity dealing with what were supposedly willful violations of a beneficent law were most disastrous to those concerned” ( Terry and Pellens 1928 , 90). “Once a strict antidrug policy had been established, both the public's and policymakers' curiosity about the details of a drug's biological effects faded. Federal scientists also feared their research findings might conflict with official policies, so they avoided some areas of investigation” ( Musto 1998 , 62).

   The medical profession withdrew from dispensing drugs to addicts, forcing them to look to illicit sources and giving rise to an enormous illegal business in drugs. People who were addicted to opium smoking eventually found their favorite drug unavailable—the bulky smoking opium was difficult to smuggle—and turned to the more readily available heroin that was prepared for intravenous use and would produce a more intense effect ( Courtwright 1982 ). The criminal syndicates that resulted from Prohibition added heroin trafficking to their business portfolios. When Prohibition was repealed in 1933, profits from bootlegging disappeared accordingly, but drug trafficking remained as an important source of revenue for organized criminal groups. (Drug trafficking is discussed in  Chapter 9 ). Law enforcement efforts against drugs have proven as ineffectual as efforts against alcohol during Prohibition, with similar problems of corruption.

   The federal government shaped vague and conflicting court decisions into definitive pronouncements reflecting the drug enforcement agency's own version of its proper role: “American administrative regulations took on the force of ruling law” ( Trebach 1982 , 132). The drug agency also embarked on a vigorous campaign to convince the public and Congress of the dangers of drugs and thereby to justify its approach to the problem of drug use. According to Bonnie and Whitebread ( 1970 , 990), the existence of a separate federal narcotics bureau “anxious to fulfill its role as crusader against the evils of narcotics” has been the single major factor in the legislative history of drug control in the United States since 1930.

   The actions of the federal government toward drug use must be understood within the context of the times. The years immediately following World War I were characterized by pervasive attitudes of nationalism and nativism and by a fear of anarchy and communism. The Bolshevik Revolution in Russia, a police strike in Boston (see  Russell 1975 ), and widespread labor unrest and violence were the backdrop for the infamous Palmer Raids of 1919, in which Attorney General A. Mitchel Palmer, disregarding a host of constitutional protections, ordered the arrest of thousands of “radicals.” That same year the Prohibition Amendment was ratified, and soon legislation ended large-scale (legal) immigration. Drug addiction—morphinism/heroinism—was added to the un-American “isms” of alcoholism, anarchism, and communism ( Musto 1973 ). In 1918, there were only 888 federal arrests for narcotics law violations; in 1920, there were 3,477. In 1925, the year the clinics were closed, there were 10,297 ( Cloyd 1982 ). “During the 1920s and 1930s,” notes Speaker (2001), “newspaper and magazine accounts of narcotics problems, and the propaganda of various anti-narcotics organizations used certain stock ideas and images to construct an intensely fearful public rhetoric about drugs. Authors routinely described drugs, users, and sellers as ‘evil,’ described sinister conspiracies to undermine American society and values, credited drugs with immense power to corrupt users, and called for complete eradication of the problem” (1).

   According to W. White ( 1998 ), Treasury Department opposition to prescribing drugs for addicts was based on a belief in the prevailing propaganda of the day with respect to alcohol treatment. “The Treasury Department opposed ambulatory treatment because, for many patients, it turned into sustained maintenance, and also because the remaining inebriate hospitals and asylums of the day were still boasting 95 percent success rates. After all, leaders of the Treasury Department argued, why should someone be maintained on morphine when all he or she had to do was to take the cure? It was through such misrepresentation of success rates that the inebriate asylums and private treatment sanitariums contributed inadvertently to the criminalization of narcotic addiction in the U.S.” (113).

   In 1923, legislation was introduced to curtail the importation of opium for the manufacture of heroin, resulting in a ban on heroin in the United States. (In 1956, Congress declared all heroin to be contraband.) Among the few witnesses who testified before Congress, all supported the legislation. The AMA had already condemned the use of heroin by physicians, and the substance was described as the most dangerous of all habit-forming drugs, some witnesses arguing that the psychological effects of heroin use serve as a stimulus to crime. Much of the medical testimony, in light of what is now known about heroin, was erroneous, but the law won easy passage in 1924 ( Musto 1973 ). A pamphlet published the same year by the prestigious Foreign Policy Association summarized contemporary thinking about heroin (cited in  Trebach 1982 ):

· ▸ It is unnecessary in the practice of medicine.

· ▸ It destroys all sense of moral responsibility.

· ▸ It is the drug of the criminal.

· ▸ It recruits its army among youths. (48)

   The use of opiates, except for narrow medical purposes, was now thoroughly criminalized, both in law and in practice. The law defined drug users as criminals, and the public viewed heroin use as the behavior of a deviant criminal class.

The Uniform Drug Act

Until 1930, efforts against drugs were primarily federal. Only a few states had drug control statutes, and these were generally ineffective ( Musto 1973 ). At the urging of federal authorities, many states enacted their own antidrug legislation. By 1931, every state restricted the sale of cocaine, and all but two restricted the sale of opiates. State statutes, however, were far from uniform. As early as 1927, this lack of uniformity, combined with the growing hysteria about dope fiends and criminality, resulted in several requests for a uniform state narcotics law. The diversity of state drug statutes was not an anachronism. The need for greater uniformity in state statutes was recognized in the first half of the nineteenth century, when a prominent New York attorney, David Dudley Field (1805–1894), campaigned for a uniform code of procedure for both civil and criminal matters. During the 1890s the American Bar Association set up the National Conference of Commissioners on Uniform State Laws, whose efforts resulted in a variety of uniform codes that were adopted by virtually all jurisdictions ( Abadinsky 2008 ).

   A uniform drug act for the states was the goal of both the Committee on the Uniform Narcotic Act and representatives of the AMA because doctors wanted uniformity of legal obligations. Their first two drafts copied a 1927 New York statute that listed coca, opium, and cannabis products as habit-forming drugs to be regulated or prohibited. Because of opposition to its inclusion on the habit-forming list, cannabis was dropped from later drafts with a note indicating that each state was free to include cannabis or not in its own legislation without affecting the rest of the act. The final draft also used the 1927 New York statute as a model and included suggestions from the newly appointed commissioner of the FBN, Harry Anslinger. The draft was adopted overwhelmingly by the National Conference of Commissioners on Uniform State Laws, to which each governor had appointed two representatives. By 1937, thirty-five states had enacted the Uniform Drug Act, and every state had enacted statutes relating to marijuana. Despite propagandizing efforts by the FBN, “The laws went unnoticed by legal commentators, the press and the public at large” ( Bonnie and Whitebread 1970 , 1034).

   The lack of public concern is related to the demographics of drug use, which was concentrated in minority, lower-class areas and the criminal subculture. Before the Harrison Act there was considerable use in rural areas; the South, where drugs often substituted for alcohol in dry areas, used more opiates than other parts of the country. After the Harrison Act addicts in rural areas were attended to quietly by sympathetic doctors. Heroin was heavily concentrated in urban areas of poverty. For example, during the early decades of the twentieth century heroin use in New York was heaviest in the Jewish and Italian areas of the Lower East Side. As these two groups climbed the economic ladder and moved out, they were replaced by African Americans looking for affordable housing and this group then became the basis of the addict population ( Helmer 1975 ). Demographics intensified the problem; African Americans had a higher birthrate than Jews and Italians, and an extraordinary number of youngsters were sixteen years old, the age of highest risk for addiction. After World War II, the white ethnic population became increasingly suburban and the inner city became increasingly black and Hispanic—a new vulnerable population in a drug-infested environment.

   Pointing to the similarities between the prohibition against alcohol and that against other drugs, David Courtwright ( 1982 ) asks why, since both reform efforts had ended in failure, did the public withdraw its support for one and increase its support of the other? “One factor (in addition to economic and political considerations) must have been that alcohol use was relatively widespread and cut across class lines. It seemed unreasonable for the government to deny a broad spectrum of otherwise normal persons access to drink. By 1930 opiate addiction, by contrast, was perceived to be concentrated in a small criminal subculture; it did not seem unreasonable for that same government to deny the morbid cravings of a deviant group” (144).

   World War II had a dramatic impact on the supply of heroin in the United States. The Japanese invasion of China interrupted supplies from that country, while the disruption of shipping routes by German submarines and attack battleships reduced the amount of heroin moving from Turkey to Marseilles to the United States. When the United States entered the war, security measures “designed to prevent infiltration of foreign spies and sabotage to naval installations made smuggling into the United States virtually impossible.” As a result, “at the end of World War II, there was an excellent chance that heroin addiction could be eliminated in the United States” ( A. W. McCoy 1972 , 15). Obviously, this did not happen (the reasons will be discussed later) and “by the 1980s, an estimated 500,000 Americans used illicit opioids (mainly heroin), mostly poor young minority men and women in the inner cities” ( Batki et al. 2005 , 13).

   The contemporary heroin market has moved well past its urban roots, becoming established in America's suburbs where it is frequently used by adolescents ( C. Buckley 2009 ). Sources of the drug vary, but can be grouped into three broad categories:

· 1. Local suburban youngsters who search out heroin connections for personal use in inner-city locations. Eventually, they begin to bring additional quantities back home for sale. This phenomenon has been seen in suburban Nassau County, on New York's Long Island ( Wolvier, Martino, Jr., and Bolger 2009 ). “The heroin being sold on Long Island is deadlier and cheaper than ever. A bag on the street costs about $6 or $7, cheaper than a pack of cigarettes. What makes the situation even more dangerous is the misconception among users that snorting or sniffing heroin, rather than injecting it, will not lead to addiction” ( “Heroin on Long Island” 2009 , 22).

· 2. Low-level urban dealers who recognize suburban locations as both lucrative and less competitive, markets they can more easily monopolize. This phenomenon has been experienced in suburbs across the Northeast ( Calefati 2008 ).

· 3. Mexican drug cartels that dispatch small cells to take advantage of fertile suburban markets. The cells take orders over disposable mobile phones and use a system of dispatchers to deliver the drugs to various rendezvous points such as a shopping center parking lot. Cell members, often-illegal immigrants, stay in one location for four or five months and are then rotated as replacements arrive. This has been experienced in suburban Ohio locations ( Archibold 2009b ). Distributors in New Jersey are targeting customers in smaller towns and rural areas to gain market share. Heroin availability has increased in Upstate New York, which has led to a corresponding increase in the number of urban and suburban youths from outlying rural counties traveling to Albany, Erie, Monroe, and Onondaga Counties to obtain the drug for personal use (National Drug Intelligence Center  2009f ).

Cocaine

Cocaine is found in significant quantities only in the leaves of two species of coca shrub that are indigenous to certain sections of South America, though they have been grown elsewhere. “For over 4,000 years among the native Andean population the coca leaf has been used in ancient rituals and for everyday gift giving. Holding spiritual, economic, and cultural significance, coca is seen as an important medium for social integration and human solidarity in the face of adverse conditions” ( Wheat and Green 1999 , 42). To the Incas the plant was of divine origin and was reserved for those who believed themselves descendants of the gods. In Bolivia it is drunk as mate (coca tea), and the leaves are chewed for hours by farmers and miners along with an alkaloid that helps to release the active ingredients. “The result is similar to a prolonged caffeine or tobacco buzz. But it is more than that. It improves stamina, is a sacred symbol central to community life and provides essential nutrients” ( Wheat and Green 1999 , 43).

   European experience with chewing coca coincided with Spanish exploration of the New World. While the early Spanish explorers, obsessed with gold, referred to coca leaf chewing with scorn, later reports about the effects of coca on Indians were more enthusiastic. Nevertheless, the chewing of coca leaves was not adopted by Europeans until the nineteenth century ( Grinspoon and Bakalar 1976 ). A “mixture of ignorance and moral hauteur played an important role in the long delay between the time Europeans first became acquainted with cocaine—in the form of coca—and the time they began to use it” ( Ashley 1975 ). The coca leaves tasted bitter and were favored by pagans—Peruvian Indians—“an obviously inferior lot who had allowed their great Inca Empire to be conquered by Pizarro and fewer than two hundred Spaniards” (3). Early records indicate that the effects of coca—stamina and energy—were ascribed not to the drug but to a pact the Indians had made with the devil or simply to delusion—the Indian is sustained by the belief that chewing coca gives him extra strength.

Nineteenth Century

Alkaloidal cocaine was isolated from the coca leaf by German scientists in the decade before the American Civil War, and the German chemical manufacturer Merck began to produce small amounts ( Karch 1998 ). Scientists experimenting with the substance noted that it showed promise as a local anesthetic and had an effect opposite that caused by morphine. Indeed, at first cocaine was used to treat morphine addiction, but the result was often a morphine addict who was also dependent on cocaine ( Van Dyke and Byck 1982 ). Enthusiasm for cocaine spread across the United States, and by the late 1880s a feel-good pharmacology based on the coca plant and its derivative cocaine emerged, as the substance was hawked for everything from headaches to hysteria. “Catarrh powders for sinus trouble and headaches—a few were nearly pure cocaine—introduced the concept of snorting” ( Gomez 1984 , 58). Patent medicines frequently contained significant amounts of cocaine

   One very popular product was the coca wine Vin Mariani, which contained two ounces of fresh coca leaves in a pint of Bordeaux wine; another, Peruvian Wine of Coca, was available for $1 a bottle through the 1902 Sears, Roebuck catalog. The most famous beverage containing coca, however, was first bottled in 1894, and an advertisement for Coca-Cola in Scientific American in 1906 publicized the use of coca as an important tonic in this “healthful drink” ( May 1988b , 29). A 1908 government report listed more than forty brands of soft drinks containing cocaine ( Helmer 1975 ). In contrast to the patent medicines, however, these beverages, including wine and Coca-Cola, contained only small, typically trivial, amounts of cocaine ( Karch 1998 ).

   In 1884, Sigmund Freud began taking cocaine and soon afterward began to treat his friend Ernst von Fleischl-Marxow, who had become a morphine addict, with cocaine. The following year, von Fleischl-Marxow suffered from toxic psychosis as a result of taking increasing amounts of cocaine by subcutaneous injection, and Freud wrote that the misuse of the substance had hastened his friend's death. Although Freud continued the recreational use of cocaine as late as 1895, his enthusiasm for its therapeutic value waned ( Byck 1974 ). Influenced by the writings of Sigmund Freud on cocaine, William Stewart Halstead, surgeon-in-chief at Johns Hopkins Hospital and the “father of American surgery,” began experimenting with the substance in 1884. When he died in 1922 at age 70, Dr. Halstead was still addicted to cocaine despite numerous attempts at curing himself ( W. L. White 1998 ).

   After the flush of enthusiasm for cocaine in the 1880s, its direct use declined. Cocaine continued to be used in a variety of potions and tonics, but unlike morphine and heroin, it did not develop a separate appeal ( H. W. Morgan 1981 ). Indeed, it gained a reputation for inducing bizarre and unpredictable behavior.

Cocaine in the Twentieth Century

After the turn of the century, cocaine, like heroin, became identified with the urban underworld and, in the South, with African Americans. “As with Chinese opium, southern blacks became a target for class conflict, and drug use became one point of tension in this larger sociopolitical struggle” ( Cloyd 1982 , 35). The campaign against cocaine took on bizarre aspects aimed at winning support for antidrug legislation among Southern politicians, who traditionally resisted federal efforts that interfered with their concept of states' rights. Without any research support, a spate of articles alleged widespread use of cocaine by African Americans, often associating such use with violence and the rape of white women ( Helmer 1975 ). Ultimately, notes Jerald Cloyd ( 1982 , 54), “Southerners were more afraid of African-Americans than of increased federal power to regulate these drugs.” At the time of the Harrison Act there was considerable discussion—but no evidence—of substantial cocaine use by blacks in Northern cities ( H. W. Morgan 1981 ).

   As with opiates, the legal use of cocaine was affected by the Pure Food and Drug Act of 1906 and finally by the Harrison Act in 1914. Before this federal legislation many states passed laws restricting the sale of cocaine, beginning with Oregon in 1887. By 1914, forty-six states had such laws, while only twenty-nine had similar laws with respect to opiates ( Grinspoon and Bakalar 1976 ). With its dangers well known, by the end of World War I, the medical community had largely lost interest in cocaine ( Karch 1998 ), and in 1922 Congress officially defined cocaine as a narcotic and prohibited the importation of most cocaine and coca leaves. This caused an increase in law enforcement efforts, and the price of cocaine increased accordingly. In 1932, amphetamines became available, and this cheap, legal stimulant helped to further decrease user interest in cocaine ( Cintron 1986 ).

   In the United States, from 1930 until the 1960s, there was limited demand for cocaine and, accordingly, only limited supply. Cocaine use was associated with deviants at the fringes of society—jazz musicians and the denizens of underworld—and sources were typically diverted from medical supplies. During the late 1960s and early 1970s attitudes toward recreational drug use became more liberal because of the wide acceptance of marijuana. Cocaine was no longer associated with deviants, and the media played a significant role in shaping public attitudes:

· By publicizing and glamorizing the lifestyle of affluent, upper-class drug dealers and the use of cocaine by celebrities and athletes, all forms of mass media created an effective advertising campaign for cocaine, and many people were taught to perceive cocaine as chic, exclusive, daring, and nonaddicting. In television specials about cocaine use, scientists talked about the intense euphoria produced by cocaine and the compulsive craving that people (and animals) develop for it. Thus, an image of cocaine as being extraordinarily powerful, and a (therefore desirable) euphoriant was promoted. ( Wesson and Smith 1985 , 193)

   Cocaine became associated with a privileged elite, and the new demand was sufficient to generate new sources. Refining and marketing networks outside of medical channels led to the development of the Latin American criminal organizations discussed in  Chapter 9 .

   During the 1980s, a new form of cocaine-called crack—became popular in a number of cities, particularly New York. Its popularity dramatically altered the drug market at the consumer level: Both users and sellers were much younger than was typical in the heroin business. Younger retailers and a competitive market increased the level of violence associated with the drug business. The appearance of this new form of cocaine, which is smoked, set off a frenzy of media interest. Elected officials responded by increasing penalties for this form of the substance as opposed to the powdered form, which is typically sniffed—a drug scare.

   Steven Belenko ( 1993 ) reports that drug scares have four common elements:

· 1. The scope of the problem is never as great as originally portrayed in the media.

· 2. Despite the media portrayals, compulsive use and addiction are not inevitable consequences of using the drug.

· 3. The violent behavior associated with the use of the drug is not as common as initially believed, nor is it necessarily caused by the drug.

· 4. The popularity of the particular drug waxes and wanes over time, and prevalence rates do not continue to increase. (24)

   By 1987, the rapid expansion of crack use stopped, and by 1989 its popularity began to diminish. The hysteria with which the media and public officials had greeted this “new scourge” was subjected to research and reflection: “Crack itself was never instantly addictive or totally devastating as asserted by the media, political speeches, and statements of public policy. In particular, it did not draw the naive and young in droves into this new and dangerous lifestyle.” Indeed, crack use was centered in those populations in which drug use has always been endemic: the urban underclass ( B. D. Johnson, Golub, and Fagan 1995 , 291).

   Cocaine has very limited medical use as a local anesthetic for ear, nose, and throat surgery. Its early use, however, led to the development of procaine (Novocain), which in 1905 was introduced into medicine and continues to be used today, particularly in dentistry ( Snyder 1986 ). Novocain and other synthetic drugs have, for the most part, replaced cocaine as a local anesthetic. Coca leaves are legally imported into the United States by a single chemical company, which extracts the cocaine for pharmaceutical purposes. The remaining leaf material, which contains no psychoactive agents, is prepared as a flavoring for Coca-Cola.

Marijuana

Cannabis sativa L., the hemp plant from which marijuana and hashish are derived, grows wild throughout most tropical and temperate regions of the world; it has been cultivated for at least 5,000 years for a variety of purposes including the manufacture of rope and paint. There is interest in the cultivation of hemp for its fiber, particularly in the American apparel and paper industries.

   Marijuana's use as an intoxicant was brought to Africa by Arab traders, and the plant was introduced into Brazil through the slave trade in the 1600s. The word marijuana (sometimes spelled “marihuana”) is derived from the Spanish term for any substance that produces intoxication: maraguano. Until the early 1900s, recreational use of marijuana was popular chiefly among Mexican laborers in the Southwest and certain fringe groups such as jazz musicians ( Weisheit 1990 ).

   In the past, most of the cannabis growing wild in the United States derived from plants originally cultivated for their fiber rather than their drug content, so their psychoactive potency was quite weak ( Peterson 1980 ). Entrepreneurial horticulturists in the United States now produce more powerful strains of the plant.

Early Marijuana Legislation and Literature

Bonnie and Whitebread ( 1970 ) state that the most prominent influence in marijuana legislation was racism: State laws against marijuana, they argue, were often part of a reaction to Mexican immigration. Before 1930, sixteen states with relatively large Mexican populations had enacted anti-marijuana legislation. “Chicanos in the Southwest were believed to be incited to violence by smoking it” ( Musto 1973 , 65). Jerome Himmelstein ( 1983 ) argues, however, that the “crucial link between Mexicans and federal marihuana policy was not locally based political pressure from the Southwest, but a specific image of marihuana that emerged from the context of marihuana use by Mexicans and was used to justify anti-marihuana legislation. Because Mexican laborers and other lower-class groups were identified as typical marihuana users, the drug was believed to cause the kinds of antisocial behavior associated with those groups, especially violent crime” (29). Because of marijuana's association with suspect marginal groups—Mexicans, artists, intellectuals, jazz musicians, bohemians, and petty criminals—it became an easy target for regulation ( Morgan 1981 ). In the eastern United States, marijuana was erroneously believed to be addictive and there was fear that it would serve as a substitute for narcotics that were outlawed by the Harrison Act.

   In light of more contemporary research into marijuana, the hysterical anti-marijuana literature that was produced during the 1930s can often seem amusing. Rowell and Rowell ( 1939 ) wrote, for example, that marijuana “seems to superimpose upon the user's character and personality a devilish form. He is one individual when normal, and an entirely different one after using marijuana” (49). According to these authors, marijuana “has led to some of the most revolting cases of sadistic rape and murder of modern times.” In 1936, the FBN presented a summary of cases that illustrate “the homicidal tendencies and the generally debasing effects which arise from the use of marijuana” ( Uelmen and Haddox 1983 , 11). The 1936 motion picture Reefer Madness showed a horrifying portrait of the marijuana user and was often featured at college marijuana parties during the 1960s.

   “It is clear,” note Bonnie and Whitebread ( 1970 , 1021–1022), “that no state undertook any empirical or scientific study of the effects of the drug. Instead they relied on lurid and often unfounded accounts of marijuana's dangers as presented in what little newspaper coverage the drug received.” By 1931, twenty-two states had marijuana legislation that was often part of a general-purpose statute against narcotics ( Bonnie and Whitebread 1970 ). Despite its being outlawed, marijuana was never an important issue in the United States until the 1960s: “It hardly ever made headlines or became the subject of highly publicized hearings and reports. Few persons knew or cared about it, and marihuana laws were passed with minimal attention” ( Himmelstein 1983 , 38).

   The FBN, operating on a Depression era budget, was reluctant to take on the additional responsibilities that would result from outlawing marijuana at the federal level. Harry J. Anslinger, FBN commissioner from 1930 until his retirement in 1962, hoped that the states would act against marijuana, leaving the bureau free to concentrate on heroin and cocaine. To get the states to act, the FBN dramatized the dangers of marijuana. But in such trying economic times, the states were reluctant to take on additional work, and the FBN's own propaganda forced it to act ( Himmelstein 1983 ).

   At the urging of Anslinger, Congress passed the Marijuana Tax Act of 1937. Because of uncertainty about the federal government's ability to outlaw marijuana, the act placed an exorbitant tax on cannabis—$100 an ounce—rather than prohibiting the substance outright. This tax act was a result of three days of congressional hearings that Bonnie and Whitebread ( 1970 , 1054) characterize as “a case study in legislative carelessness.” Commissioner Anslinger was able to orchestrate an undocumented and hysterical presentation before the House Ways and Means Committee on the dangers of marijuana, and the floor debate on the bill, Bonnie and Whitebread argue, represented a near-comic example of dereliction of legislative responsibility. Anslinger and Tompkins ( 1953 ) maintained that marijuana was “a scourge which undermines its victims and degrades them mentally, morally, and physically” (20–21). The AMA's opposition to the bill was ridiculed by members of the Ways and Means Committee. Marijuana was being treated as just another narcotic ( Bonnie and Whitebread 1970 ). The states followed the federal lead and increased their penalties for drug violations, including marijuana. In 1951, penalties for possession and trafficking in marijuana were substantially increased— along with those for other controlled substances—with the passage of the Boggs Act (discussed below).

Counterculture Use and Changing Laws

During the 1960s, public attitudes toward marijuana underwent considerable change. A nonconformist counterculture, whose members were often from the white middle class, emerged. The rebellious nature of the hippies encouraged greater experimentation with sex and drugs, marijuana in particular. In fact, note Lidz and Walker ( 1980 ), marijuana use helped to tie together diverse interests: civil rights, antiwar, and antiestablishment groups and individuals. Its primary importance was as a membership ritual for an otherwise very diffuse and disorganized culture. No longer confined to minority or subcultural groups—Chicanos, African Americans, beatniks, musicians—marijuana soon found widespread acceptance among people of the middle and upper classes. This led to significant scientific inquiry into the effects of marijuana, and toward the latter part of the 1960s it became clear that whatever its dangers might be, the substance was simply not in the same class as heroin or cocaine on any important pharmacological dimension. Young, white, middle-class users, however, like their ghetto counterparts, were being subjected to the significant penalties that obtained for heroin and cocaine.

   The rise of middle-class marijuana users offered the public a new view of the phenomenon in Lifemagazine's October 31, 1969, issue. Marijuana was the lead story, and the magazine presented photographs of white, middle-class people enjoying marijuana in a variety of congenial social settings. Also included was an in-depth story of a young man from Nashville, Tennessee, a long-distance runner and prep school graduate attending the University of Virginia on an athletic scholarship. He was arrested for possession of three pounds of marijuana and in a Virginia state court received a sentence of twenty years in prison. The same issue of Life contains an article by the former director of the U.S. Food and Drug Administration (FDA), James L. Goddard (1969), who stated: “Our laws governing marijuana are a mixture of bad science and poor understanding of the role of law as a deterrent force. They are unenforceable, excessively severe, scientifically incorrect and revealing our ignorance of human behavior” (34). The following year Robert F. Kennedy, Jr. and R. Sargent Shriver III, juveniles at the time, were arrested for possession of marijuana. Public pressure soon caused legislators to reconsider state and federal penalties for marijuana.

   “As of 1965, marihuana laws still bore the mark of the harsh legislation of the 1950s. Simple possession carried penalties of two years for the first offense, five for the second, and ten for the third” ( Himmelstein 1983 , 103). By the end of the 1960s, penalties on the state level had been significantly reduced. However, the Comprehensive Drug Use Prevention and Control Act of 1970 established five schedules for controlled substances, and marijuana, along with heroin, was placed in the highest category, Schedule I.

   In 1972, the presidentially appointed National Commission on Marijuana and Drug Use recommended that possession of marijuana for personal use or noncommercial distribution be decriminalized. The following year Oregon became the first state to abolish criminal penalties for the possession of one ounce or less of marijuana, replacing incarceration with relatively small fines. In 1975 California made possession of one ounce or less of marijuana a citable misdemeanor with a maximum penalty of $100, and there were no increased penalties for recidivists. By 1978, eleven states had decriminalized marijuana. Despite vigorous opposition at the federal level, a number of states authorize physicians to prescribe marijuana.

Amphetamine

Manufactured under the trade name Benzedrine, in 1932 amphetamine was marketed as an inhalant, and subsequently in tablet form, for use as a nasal decongestant. It was introduced into clinical use during the 1930s and eventually offered as a “cure-all” for just about every ailment. Between 1932 and 1946, there were thirty-nine generally accepted medical uses for amphetamines, including the treatment of schizophrenia, morphine addiction, low blood pressure, and caffeine and tobacco dependence ( D. E. Smith 1979 ). “Amphetamines were unique: never before had a powerful psychoactive drug been introduced in such quantities in so short a period of time, and never before had a drug with such a high addictive potential and capability of causing long-term or irreversible physical and psychological damage been so enthusiastically embraced by the medical profession as a panacea or so extravagantly promoted by the drug industry” ( Grinspoon and Hedblom 1975 , 13).

   By the end of the decade, as their stimulating properties became widely known, amphetamines were used primarily as analeptics—stimulating drugs. Many amphetamine-based inhalants appeared on the market and were widely available without prescription. These quickly became the subject of widespread use. During World War II, British, German, and Japanese governments issued amphetamines to soldiers to elevate mood and to counteract fatigue and pain, and U.S. military personnel were exposed to their use through contact with the British military. During the Korean conflict the United States authorized the distribution of amphetamines to military personnel. The first major wave of use appeared when American servicemen in Korea and Japan mixed the substance with heroin to create “speedballs,” which were taken intravenously ( Grinspoon and Hedblom 1975 ).

   Amphetamines were widely prescribed in the 1950s and 1960s as an aid in dieting, leading to use by housewives taking “diet pills.” Ralph Weisheit and William White (2009, 29) note that a surge in amphetamine use in the United States began with a core of people exposed through medicine or the military and then “spread outward into the mainstream population through new forms of the drug, excessive drug supply (from overproduction), and overprescribing.” “Pep pills” moved from the beatnik subculture, to students and long-distance truck drivers as an aid in staying awake, and then to the wider population.

   In the 1960s, the FDA launched a widespread anti-amphetamine campaign with the slogan “Speed Kills” ( R. O'Brien and Cohen 1984 ); in 1971, federal laws restricted the conditions under which amphetamines could be prescribed. During the late 1980s, the smokable crystal methamphetamine, called ice, appeared on the drug scene. Media and political concern over the possible spread of this new form of drug led to a new drug scare. Widespread use continues, particularly in more rural parts of the country where the drug is often manufactured.

Barbiturates

Barbiturates are sedating drugs synthesized from barbituric acid. Barbituric acid was first synthesized in Germany in 1863 by Nobel Prize–winning chemist Adolf von Baeyer. The first barbiturate was synthesized in 1882 but not marketed until 1903 ( McKim 1991 ). Accounts vary as to how barbituric acid acquired its name. In 1903, it was released under the trade name Veronal, a name derived from the Italian city of Verona. It is known generically in the United States as barbital ( Wesson and Smith 1977 ).

   Barbiturates were used to induce sleep, replacing other aids such as alcohol and opiates. Since the appearance of phenobarbital in 1912, thousands of barbituric acid derivatives have been synthesized, although only about a dozen are commonly used; these are marketed under a variety of brand names. Barbiturates were widely prescribed in the United States during the 1930s, when their toxic effects were not fully understood. By 1942 there were campaigns against the nonmedical use of barbiturates, and by the 1950s barbiturates were one of the major drugs of abuse among adults in the United States. In the 1960s, barbiturate use quickly spread to the youth population ( R. O'Brien and Cohen 1984 ). Nonmedical use of barbiturates is usually the result of diverting licit supplies through theft or burglary, forged prescriptions, or illegal manufacture in other countries, particularly Mexico. Supplies diverted from licit sources may be repackaged in nondescript capsules, thus disguising their source ( Wesson and Smith 1977 ).

Tranquilizers and Sedatives

Along with amphetamines and barbiturates, many doctors in the 1960s routinely prescribed a variety of substances to reduce anxiety. Tranquilizers or sedatives, such as Miltown and Valium, enabled millions of housewives to “get by with a little help from their friends.” These substances were the subject of heavy advertising, much of it depicting women in need of relief from tension and anxiety, by drug companies that offered their products as aids in coping with the normal problems of life. Consumers often became so dependent on these substances that they could not function without them, having lost the ability to deal with normal levels of stress. As a result of unfavorable attention by health and consumer organizations and a congressional hearing in 1979, the manufacturers of Valium and other tranquilizers shifted their focus to promote these substances' ability to ease the stress of modern living. In 1980, the FDA required tranquilizers to be labeled as generally not appropriate for anxiety or tension associated with the stress of everyday life.

Hallucinogens

Hallucinogens such as LSD became popular during the 1960s, particularly among rebellious college students and people who identified themselves as antiestablishment. Lester Grinspoon ( 1979 ) states: “It is impossible to write an adequate history of such an amorphous phenomenon [LSD] without discussing the whole cultural rebellion of the 1960s” (57). LSD was first synthesized in Switzerland in 1938, but its hallucinogenic qualities did not become apparent until its discoverer took his first “trip” in 1943.

   Between 1949 and 1962, the LSD became the focus of research in the United States among a small number of psychiatrists and psychologists for treating psychiatric disorders ( Brecher 1972 ;  Stevens 1987 ). The U.S. Army and the Central Intelligence Agency, too, were also interested in this research as well as conducting LSD experiments on soldiers and civilians, usually without their knowledge or consent, to test its suitability for chemical warfare and as a “truth serum” ( Henderson 1994a ).

   Two psychologists, Timothy Leary and Richard Alpert of Harvard experimented with the hallucinogenic mushroom psilocybin. While the “Psilo-cybin Project” began as a scientific endeavor, it ended as casual use of the drug by many friends and acquaintances, including a small clique of psychedelic enthusiasts such as the authors Aldous Huxley (Brave New World) and Ken Kesey (One Flew Over the Cuckoo's Nest) and the poet Allen Ginsberg (see Wolfe [ 1968 ] for a look at Kesey and his Merry Pranksters' psychedelic world). Leary began encouraging his psychology students to use psilocybin. Word of their activities spread beyond the Harvard community when it was picked up by newspapers as a result of a story in the Harvard Crimson. Federal agencies began making inquiries. School officials were anxious to rid themselves of Leary and Alpert, so their research and control over psilocybin were placed under a faculty committee while the school awaited the expiration of Leary and Alpert's teaching contracts. No matter, they had been introduced to LSD.

   In 1963, an editorial attacking LSD appeared in the Journal of the American Medical Association, and in 1965 LSD was outlawed in the United States. Nevertheless, Leary popularized the use of LSD, and as a result of his Harvard connection, LSD gained the attention of the mass media ( Grinspoon 1979 ). As a self-appointed High Priest of LSD (the title of Leary's book), he traveled widely and lectured on the virtues of using acid to “turn on, tune in, and drop out.” LSD use became part of the counterculture and the antiwar movement and “in a major city like Los Angeles,” notes Jay Stevens ( 1987 ), “it was as easy to go on an LSD trip as it was to visit Disneyland” (171). “Acid rock” songs such as “White Rabbit” by the Jefferson Airplane, “Sunshine Superman” by Donovan, and the Beatles' “Magical Mystery Tour” and “Lucy in the Sky with Diamonds” became top hits.

Government Action after World War II

In the years immediately before World War II, the FBN seemed to have the drug problem well under control. Commissioner Anslinger released statistics indicating a significant drop in the addict population. Then came the war. Opiate smuggling dwindled, and Americans of an age most susceptible to drug use were in Europe and Asia. Drug use was viewed as unpatriotic as well as illegal. Alcohol, barbiturates, and amphetamines were the substances most widely used during the war years, when the price of opiates increased dramatically. The addict population appeared to reach an all-time low.

   At the end of the war, there was fear of an epidemic of drug use as U.S. soldiers began to return from Far Eastern locations where opiate use was endemic. The epidemic failed to materialize. The FBN became a victim of its own propaganda and apparent success, and Congress would not increase the drug-fighting budget ( H. W. Morgan 1981 ). Then, in 1950 and 1951, a spate of news stories on drug use reported that the use of heroin was spilling out of the ghetto and into middle-class environs, where it was poisoning the minds and bodies of America's (white) youth. Musto ( 1973 ) points out a parallel between the periods following World War I and World War II: Both were characterized by an atmosphere of hostility to radicals and Communists, and both led to punitive sanctions against drug addicts. Any expression of tolerance for radical political ideas or drug addicts was un-American. In a timely stroke of political genius, the FBN linked heroin trafficking to Red China.

   Anslinger accused the People's Republic of China of selling opium and heroin to the free nations of the world to finance overseas ambitions ( Cloyd 1982 ). As we shall see in  Chapter 9 , Far Eastern heroin was, and continues to be, the business of Chinese Nationalists, triads, Thais, and Burmese insurgents—not the People's Republic, which routinely executes drug traffickers. Indeed, “at the time of the Communist takeover in 1949, China was the world's largest producer and consumer of narcotic drugs” ( Lee 1995 , 194). The 1949 takeover of the Chinese mainland by the forces of Mao Zedong and the Communist Party eventually led in the elimination of domestic opium production in China.

   On the basis of statistics showing that between 1946 and 1950, there had been a 100 percent increase in the number of arrests related to narcotics laws and that over a five-year period the average age of people committed to Public Health Service hospitals had declined from 37.5 to 26.7 years, Congress concluded that drug addiction was increasing and that penalties for drug trafficking were inadequate. In 1951, Congress passed the Boggs Act, which increased penalties for violations of drug laws. Once again, using rather dubious statistical data, Congress concluded that the increased penalties of the Boggs Act had been quite successful in reducing drug trafficking. As a result, in 1956 Congress passed the Narcotic Control Act, which further increased the penalties for drug violations, for example, the sale of heroin to individuals under 18 years of age was made a capital offense; the Act also increased the authority of the FBN and agents of the Customs Bureau ( PCOC 1986 ). State legislatures, responding to the federal initiative, significantly increased penalties for drug violations.

   “Public concern over the problem of drug use, which had been relatively dormant during the 1940s and 1950s, flared again during the 1960s. The intensification of national concern resulted in increasing pressure for federal initiatives in the area. In response to this development, a White House Conference on Narcotics and Drug Use was convened in 1962, which resulted in the establishment of the President's Advisory Commission on Narcotics and Drug Use (Prettyman Commission) on January 15, 1963” ( PCOC 1986 , 215). The commission recommended discarding the antiquated legal notion that drug control was simply a taxing measure, and they suggested that the responsibilities of the FBN be transferred to the Department of Justice. On the other hand, the commission recommended that the regulation of marijuana and lawful narcotic drugs be transferred from the FBN to the Department of Health, Education, and Welfare (HEW). It also recommended increasing the number of federal drug agents and enacting legislation for the strict control of nonnarcotic drugs capable of producing psychotoxic effects when used.

   In the 1960s, concern increased over the diversion of dangerous drugs from licit sources. As a result, Congress passed the Drug Use Control Amendments of 1965, which, among other things, mandated record-keeping and inspection requirements for depressant and stimulant drugs throughout the chain of distribution, from the basic manufacturer to (but not including) the consumer. Enforcement of the 1965 legislation was left to a newly created agency within HEW's Food and Drug Administration: the Bureau of Drug Use Control. The Treasury Department's monopoly over drug enforcement had ended ( PCOC 1986 ).

A Turn toward Treatment

During the 1960s the medical profession began to reassert itself on the issue of drug use in both treatment and research. Treating disciplines—psychology and social work—and researchers in sociology and public health began to focus on the drug issue as a social problem, not simply a law enforcement problem. The social activism of the 1960s also influenced the perspective on drug use ( H. W. Morgan 1981 ), and a new strategic approach was implemented: reducing demand by rehabilitating large numbers of drug addicts. Arnold Trebach ( 1982 ) argues that this approach was facilitated by the resignation of Harry Anslinger as commissioner of the FBN, “which had been accomplished with the active encouragement of the Kennedy brothers [i.e., President John F. and Attorney General Robert F.]” (226). Harry Giordano, a pharmacist and Anslinger's replacement, shifted drug policy away from a law enforcement model toward a treatment model. The 1963 Prettyman Commission recommended the relaxation of mandatory prison sentences for drug convictions, greater research, and the dismantling of the FBN, whose functions were to be divided between HEW (prevention and treatment), and the Department of Justice (law enforcement).

   In 1961, California established a civil commitment program in which drug addicts were taken into custody and committed—like mentally ill people in need of hospitalization—to a nonpunitive period of confinement and drug treatment. Confinement was followed by a period of aftercare (parole supervision). In 1966, New York established the Narcotic Addiction Control Commission, a large-scale effort whose goal was to confine as many drug addicts as possible under civil commitment statutes. As in California, whose lead New York was following, confinement was followed by a period of parole supervision. (This writer was employed briefly as a senior narcotics parole officer for the Narcotic Addiction Control Commission. This agency, which expended billions of dollars, was dismantled during the 1970s as a very costly failure.)

   Also in 1966, Congress passed the Narcotic Addict Rehabilitation Act, which in lieu of prosecution authorized federal district courts to order the voluntary and involuntary civil commitment of certain defendants who were found to be drug addicts and mandated the Surgeon General to establish rehabilitation and posthospitalization care programs for drug addicts. The legislation also authorized the financing of state efforts to treat addicts.

   Between 1969 and 1974 the number of federally funded drug rehabilitation programs dramatically increased from sixteen at the beginning of 1969 to 926 in 1974. Federal expenditures on drug treatment rose from about $80 million to about $800 million during that period. About half of the 80,000 clients in these programs were being maintained on methadone ( Moss 1977 ).

Comprehensive Drug Use Prevention and Control Act of 1970

As the end of the 1960s approached, alarming statistics of dubious validity about drug use appeared. The drug problem soon became a major political issue. In 1968, President Lyndon Johnson decried the fragmented approach to drug law enforcement. With congressional approval, the President abolished the FBN and the Bureau of Drug Use Control and transferred their responsibilities to a newly created agency, the Bureau of Narcotics and Dangerous Drugs (BNDD), in the Department of Justice. Revenue and importation aspects of drug trafficking remained within the IRS and Bureau of Customs. In 1970, President Richard Nixon clarified the responsibilities of the federal agencies involved in drug control, announcing that BNDD “controls all investigations involving violations of the laws of the United States relating to narcotics, marijuana and dangerous drugs, both within the United States and beyond its borders.” Several months later guidelines were promulgated that provided increased authority for customs officials at ports and borders.

   The two-pronged approach to dealing with drug use—reducing availability by investigating and prosecuting traffickers and reducing demand by preventing addiction and treating addicts—was now firm policy. The Comprehensive Drug Use Prevention and Control Act of 1970 authorized HEW to increase its efforts at prevention and rehabilitation through a program of grants to special projects and made the HEW National Institute on Drug Use, the agency with primary responsibility for drug education and prevention activities. The legislation also established five schedules into which all controlled substances could be placed according to their potential for use, imposed additional reporting requirements for manufacturers, distributors, and dispensers; promulgated new regulations for the importation of controlled substances; and established the Commission on Marijuana and Drug Use.

   The 1970 legislation represented a new legal approach to federal drug policy. It was predicated not on the constitutional power to tax, but on federal authority over interstate commerce. The President's Commission on Organized Crime ( 1986 ) notes that this shift had enormous implications for the way in which the federal government would approach drug enforcement in the future. The act “set the stage for an innovation in federal drug law enforcement techniques. That innovation was the assigning of large numbers of federal narcotic agents to work in local communities. No longer was it necessary to demonstrate interstate traffic to justify federal participation in combating illegal drug use” (228). The new approach was upheld by decisions of the Supreme Court, and the National Conference of Commissioners on Uniform State Laws drafted a model act based on the 1970 statutes, which has been adopted by most states.

   A 1973 reorganization plan led to the creation of the Drug Enforcement Administration (DEA) within the Department of Justice. All investigative and enforcement responsibilities for drug control, except those related to ports of entry and borders, were given over to the new agency. In 1982, the Federal Bureau of Investigation (FBI) was given concurrent jurisdiction with the DEA for drug investigation and law enforcement. In addition, the DEA director was required to report to the director of the FBI, who was given responsibility for supervising drug law enforcement efforts and policies. That same year the Department of Defense Authorization Act contained a provision outlining military cooperation with civilian authorities. This provision was aimed at improving the level of cooperation by delineating precisely what assistance military commanders could provide. It also permits military personnel to operate military equipment that had been loaned to civilian drug enforcement agencies ( PCOC 1986 ).

Drug Scare of the 1980s

As 1980 approached, the lack of public interest in and even tolerance of drug use began to shift as grassroots parent groups began to influence the political landscape. A mother “who later presided over the National Federation of Parents for Drug-Free Youth, attended a rock concert in 1978 with her two young children and discovered rampant drug use all around them. Her anger, shared by others she contacted, apparently was a major factor in the defeat of her Congressman, … who had sponsored a bill favoring the decriminalization of an ounce of marijuana. That a broad base of parents were antagonistic to drugs and that they were now organizing their political power had been demonstrated” ( Musto 1987 , 271). With encouragement from Dr. Robert L. DuPont, then director of the National Institute on Drug Use, an “antipot” handbook for parents was published. The antidrug theme was soon picked up by the Reagan Administration.

   The issue of drug abuse is politically safe and useful because no one is in favor of it. During the presidency of Ronald Reagan, drugs again became a major political issue. On June 19, 1986, Len Bias, a basketball star from the University of Maryland, died of a cocaine overdose; on June 27, Don Rogers, a defensive back for the Cleveland Browns, also died of a cocaine overdose. These widely reported incidents, occurring within a short time of each other and less than five months before congressional elections, led to an intensification of antidrug efforts, a widespread public relations effort utilizing sports and entertainment personalities whose message to television viewers was “Just Say No!” (to drugs). Not to be outdone, Congress responded with huge allocations to combat this scourge, and politicians scrambled for partisan advantage. “Len Bias’ death brought together the political and human aspects of drug use. His death accentuated that attention placed on drugs after the announcement of the ‘war on drugs.’ Although consensus about the need to ‘do something’ was generally accepted, politicians continued to argue over the best approach” ( Merriam 1989 , 25).

   The fight against drugs and drug use was an important issue in the presidential campaign of 1988. The heat of the national campaign led to the enactment of an omnibus drug bill (the Anti-Drug Use Act of 1988) in the final days of the 100th Congress. The legislation states: “It is the declared policy of the United States Government to create a Drug-Free America by 1995.” The statute mandated greater controls over precursor chemicals and devices used to manufacture drugs, such as encapsulating machinery. It also created a complex and extensive body of civil penalties aimed at casual users, including fines and ineligibility for federal benefits such as educational loans and mortgage guarantees and/or the loss of a maritime, pilot, or stockbroker license for a number of years. Penalties were enhanced for selling drugs to minors, and a judge was empowered to impose the death penalty for murders committed as part of a continuing criminal enterprise or for the murder of a law enforcement officer during an arrest for a drug-related felony.

   The legislation also established the Office of National Drug Control Policy headed by a director (“drug czar”) appointed by the President. The director is charged with coordinating federal drug supply reduction efforts, including international control, intelligence, interdiction, domestic drug law enforcement, treatment, education, and research, and serves as a liaison between the federal government and state and local drug control efforts. The first director was William J. Bennett, who served as drug czar for twenty-two months, using the position primarily as a rhetorical platform to focus attention on the issue of drug use as seen by the administration. His approach attracted extensive media attention, but the powers of the director are so circumscribed that he accomplished little else.

   The medical profession returned to a role in responding to drug use and addiction medicine grew rapidly between the 1960s and 1980s, largely due to the efforts of physicians from New York, California, and Georgia—many were themselves recovering addicts (Freed 2007). Their efforts led to the establishment of the American Society of Addiction Medicine. Psychiatrists responded that substance use was often part of a co-occurring psychiatric disorder—comorbidity—that they were uniquely qualified to treat and in 1985, psychiatrists established what is now known as the Academy of Addiction Psychiatry. In 1991, addiction psychiatry became a board-recognized subspecialty under the American Board of Psychiatry and Neurology (Freed 2007). In 1989, the American Society of Addiction Medicine was admitted to the American Medical Association (AMA) and in 1990 the AMA added addiction medicine to its list of designated specialties.

The Twenty-First Century

The 1990s began a remarkable period of a lack of political interest in drug use. Indeed, as officials began to recognize the extent of prison overcrowding resulting from state and federal drug policies, statutory and administrative remedies were formulated that placed more drug offenders in diversion or drug treatment programs, on probation, and on parole. Laws providing significantly greater prison sentences for the sellers of crack cocaine than for sellers of powdered cocaine came under fire because the former substance is more likely to be used by minorities, the latter by middle-class whites. There is a mandatory five-year minimum for selling 5 grams of crack or 500 grams of powdered cocaine and ten years for selling 50 grams of crack or 5,000 grams of powdered cocaine.

   With the new century, the use of methamphetamine increased, with new supplies coming from Mexico. In some areas methamphetamine became as popular as cocaine. The twenty-first century, too, saw a rise in the use of methamphetamine in rural parts of the United States, while in urban areas crack use has ceased to be an epidemic. Concern over the nonmedical use of prescription medicine has led the government to focus on that problem.

   Marijuana has and still remains readily available, and both its use and sale transcend ethnic, racial, and gender boundaries. Its legalization, too, as well as medical marijuana are common topics in the mainstream media.

   While cocaine still remained the dominant (illegal) drug, heroin, prepared for smoking and snorting, made a comeback, particularly outside its typical core clientele, the urban poor. This revival, which was fueled by the availability of high-grade heroin, particularly from Colombia, is following a pattern set by cocaine in the 1970s. The abundance of heroin is reflected in the purity levels found at the retail level.

Chapter Summary

· 1. Know the popular prejudices against racial and ethnic groups that determined drug policy:

· • Race, religion, and ethnicity have been closely identified with the reaction to drugs in the United States: the Irish and alcohol; the Chinese and opium; African-Americans and cocaine; and, finally, Mexicans and marijuana.

· • Opposition to alcohol was often intertwined with nativism, and efforts against alcohol and other psychoactive drugs were often a thinly veiled reaction to minority groups.

· 2. Know the history of Prohibition:

· • The organized movement to prohibit alcohol dates back to 1808.

· • The abstinence/prohibition view differs from the modern alcoholism movement in that it maintained that alcohol is inevitably dangerous for everyone.

· • Big business was also interested in prohibition. Alcohol contributed to industrial inefficiency, labor strife, and the saloon, which served the interests of urban machine politics.

· • Prohibition became effective in 1920 and that year the Volstead Act provided for federal enforcement.

· • Primary resistance to Prohibition resulted in disregard for laws in general—negative contagion.

· • Prohibition served to make organized crime a potent force.

· • When Prohibition ended, criminal organizations became involved in the drug trade.

· 3. Understand why policy toward opiates did not change until 1914:

· • During the second half of the nineteenth century, morphine and heroin were widely available.

· • Opiates were the primary ingredient in many “patent medicines.”

· • The publication of Upton Sinclair's The Jungle in 1906 led to the passage of the Pure Food and Drug Act and an end to the patent medicine industry.

· • During the nineteenth century, opiates were not associated with crime in the public mind.

· • Beginning in 1898, heroin was marketed as a safe, nonaddictive substitute for morphine.

· • The outlawing of the nonmedical use of opiates was a result of the Opium Wars.

· • The international U.S. response to drugs in the twentieth century is directly related to trade with China.

· • Foreign, not domestic, issues led to the passage of the Harrison Act in 1914 curtailing the nonmedical use of opiates and coca products.

· • The Harrison Act represented this country's attempt to carry out the provisions of the Hague Convention.

· • Concern with federalism led Congress to use the taxing authority of the federal government to control drugs.

· • The outlawing of the nonmedical use of opiates resulted in a changed view of opiate users.

· • Supreme Court decisions found that a doctor who prescribed small doses of drugs for the relief of an addict did not violate the Harrison Act.

· • Despite Court decisions, federal drug enforcement arrested doctors who prescribed narcotics for addicts and raided drug clinics.

· 4. Know why cocaine never proved as popular as opiates until the 1960s:

· • Because it had an effect opposite of opiates, cocaine was used to treat morphine addiction.

· • By the late 1880s a feel-good pharmacology based on the coca plant and its derivative cocaine emerged.

· • The initial enthusiasm for cocaine in the 1880s use declined until a reemergence in the 1960s.

· • Crack cocaine became the subject of a drug scare.

· 5. Recognize how marijuana emerged as a symbol of nonconformity and eventually a political issue:

· • During the 1960s public attitudes toward marijuana underwent considerable change. A nonconformist counterculture, whose members were often from the white middle class, emerged.

· • The change in who was using marijuana in the 1960s led to a change in attitude toward the drug and its users.

· • In 2012, medical marijuana and the legalization of marijuana became political issues.

· 6. Know the history of the use of amphetamines:

· • The widespread use of amphetamines in the 1960s was the subject of an FDA campaign and laws restricting its use.

· • Widespread use in the form of methamphetame continues, particularly in more rural parts of the country where the drug is often manufactured.

· 7. Know the history of the use of barbiturates and tranquilizers:

· • Medical use of barbiturates has been largely replaced by benzodiazepines.

· • In 1980 the Food and Drug Administration required tranquilizers to be labeled as generally not appropriate for anxiety or tension associated with the stress of everyday life.

· 8. Know the history of the use of hallucinogens:

· • LSD was virtually unknown before 1962 when popularized by two Harvard psychologists.

· • LSD was outlawed despite interest in its medical use.

· 9. Understand why drugs became a major political issue from the 1960s through the 1980s:

· • During the 1960s the medical profession began to reassert itself on the issue of drug use in both treatment and research.

· • Between 1969 and 1974 the number of federally funded drug rehabilitation programs increased dramatically with thousands of heroin addicts being maintained on methadone.

· • During the presidency of Ronald Reagan drugs again became a political issue and the “war on drugs” was important in the 1988 presidential campaign.

· 10. Appreciate why drugs as a political issue became dormant:

· • The 1990s was characterized by a lack of political interest in drug use and the extent of prison overcrowding resulting from drug policies resulted in remedies that placed more drug offenders in diversion or drug treatment programs.

· • The twenty-first century has been characterized by a rise in the use of methamphetamine in rural parts, while in urban areas crack use has ceased to be an epidemic.

· • Concern over the nonmedical use of prescription drugs gained government attention.

Review Questions

· 1. What handicaps historical analysis of drug use?

· 2. What is the connection between support for Prohibition and nativism?

· 3. Why did big business support Prohibition?

· 4. What is negative contagion?

· 5. What was the patent medicine problem?

· 6. What is the connection between the Opium Wars and the outlawing of the nonmedical use of opiates?

· 7. How did the outlawing of the nonmedical use of opiates change the public view of opiate users?

· 8. What is the connection between the 1906 publication of Upton Sinclair's The Jungle in 1906 and the enactment of the Pure Food and Drug Act?

· 9. What events led to the passage of the Harrison Act in 1914?

· 10. Why did Congress use the taxing authority of the federal government to control drugs?

· 11. What did the Supreme Court rule with respect to the Harrison Act?

· 12. How did federal drug enforcement influence drug policy?

· 13. Why were amphetamines used by various militaries during wartime?

· 14. How did World War II impact on heroin use in the U.S.?

· 15. What led to the decline in interest in cocaine use and its reemergence in the 1960s?

· 16. What are the common elements of a drug scare?

· 17. What is the connection between race, religion, and ethnicity have been closely identified with the reaction to drugs in the United States?

· 18. Why did attitudes toward marijuana change during the 1960s.

· 19. What led to the increased interest in LSD during the 1960s?

· 20. What are the elements that characterize the drug problem of the twenty-first century?

CHAPTER 9 DRUG TRAFFICKING

Mexican soldiers next to 3.5 tons cocaine found when a jet from Colombia was forced to land by the Mexican Air Force

After reading this chapter, you will:

· ▸ Appreciate that the law of supply and demand governs the illegal drug market

· ▸ Know the connection between drug trafficking and terrorism

· ▸ Understand why Colombia, Mexico, the Golden Triangle, and the Golden Crescent are the source of most of the world's illegal drugs

· ▸ Know the many ways to smuggle drugs into the United States

· ▸ Understand the persons and groups that operate at the retail level of drug trafficking

· ▸ Appreciate why rural areas have become hospitable to marijuana cultivation and methamphetamine production

· ▸ Know how and why upper-level drug traffickers engage in money laundering

Underground Railroad

Originating in Tijuana, Mexico, the tunnel ran for almost half a mile, with wooden planks shoring up the earth on all sides. Energy-saving light bulbs illuminated the route, and a motorized cart on railroad tracks provided quick passage to California, where a steel elevator hidden beneath the floor tiles in a warehouse enabled a forty-foot descent to the tunnel's entrance. Discovered by Mexican authorities in 2011, it is but one of more than a hundred tunnels providing a steady flow of tons of drugs into the United States.

Source: Cave 2011 ;  Keefe 2012 .

“  While opium used to be produced in a huge belt, stretching from China to Indochina, Burma, India, Persia, Turkey and the Balkan countries, the illegal production of opium is now concentrated in Afghanistan (92%). Same for coca. Its leaves used to be cultivated not only in the Andean region but also in several Asian countries including Java (Indonesia), Formosa (Taiwan) and Ceylon (Sri Lanka). Today coca leaf production is concentrated in three Andean countries: Colombia, Peru and Bolivia.

—Antonio Maria Costa ( 2009 , 3)

This chapter examines the international and domestic traffic in illegal drugs that by any estimate, is a multibillion-dollar-a-year industry with enormous profit-to-cost ratios. For example, heroin can be purchased in 700-gram units in Bangkok, Thailand, for between $7,500 and $9,500 and sold in the United States for $60,000 to $70,000. Because the product is illegal but in great demand, drug trafficking is characterized by a level of free enterprise that Adam Smith never envisioned. It is a market totally devoid of legal constraints in which prices and profits are governed only by the law of supply and demand.

   The business of illegal drugs shares some elements with the business of selling legal products: “It requires lots of working capital, steady supplies of raw materials, sophisticated manufacturing facilities, reliable shipping contractors and wholesale distributors, the all-important marketing arms and access to retail franchises for maximum market penetration” ( Brzezinski 2002 , 26). Longmire ( 2011 ) notes that drug “cartels are run like profit-seeking corporations; so when the market makes a move, so do they.” She points out that “over the years, they have shown an amazing ability to adjust to changing drug-consumer tastes and increasing law enforcement initiatives.” Mexican and Colombia cartels “keep a constant finger on the pulse of U.S. demand for drugs in order to keep their biggest consumer happy” (10).

   As in any major industry there are various functional levels: manufacturers, importers, wholesalers, distributors, retailers, and consumers. Workers in the drug business range from leaders of powerful international cartels to street dealers whose activities support a personal drug habit. At the manufacturing and importation levels, the drug business is usually concentrated among a relatively few people who head major trafficking organizations; at the retail level, it is filled with a large, fluctuating, and open-ended number of dealers and consumers. Because people at the highest levels of the drug trade are often connected by kinship and ethnicity, we will frequently refer to the ethnicity of criminal organizations.

   For decades, the American Mafia controlled heroin trafficked into the United States. In a drug-trafficking network that became known as the “French Connection,” New York City—based American Mafia Families purchased heroin from Corsican sources working with French sailors operating from Marseilles to transship the drug directly to the United States where it was distributed to drug dealers working in low-income, minority communities. However, in 1972, French and U.S. drug agents effectively dismantled the French Connection, ending the American Mafia's monopoly on heroin distribution in the United States.

   The demise of the French Connection coupled with the subsequent emergence of criminal syndicates based in Mexico and Colombia marked a significant evolution in the international drug trade. These new traffickers introduced cocaine into the United States on a massive scale, launching unparalleled waves of drug crimes and violence. Throughout the 1980s and 1990s, the foreign crime syndicates continued to increase their wealth and dominance over the U.S. drug trade, overshadowing the domestic Mafia Families.

   Today, at the highest levels of trafficking in illegal drugs destined for the United States are organizations based in Colombia and Mexico who produce and export unprecedented volumes of cocaine, methamphetamine, heroin, and marijuana. The trafficking hierarchy maintains control of workers through highly compartmentalized cell structures that separate production, shipment, distribution, money laundering, communications, security, and recruitment. These organizations have at their disposal the most technologically advanced aircraft, vessels, vehicles, radar, communications equipment, and weapons that money can buy. They have established vast counterintelligence capabilities and transportation networks. There is also the connection between drug trafficking and terrorism.

The Terrorism Connection

The globalization of organized crime created a nexus with terrorism. In years past, transnational organized crime “was largely regional in scope, hierarchically structured, and had only occasional links to terrorism. Today's criminal networks are fluid, striking new alliances with other networks around the world and engaging in a wide range of illicit activities, including cybercrime and providing support for terrorism” (Strategy to Combat Transnational Organized Crime 2011, 3).

   The links between terrorist organizations and drug traffickers can take many forms, ranging from facilitation—protection, transportation, and taxation—to direct trafficking by terrorists to finance activities. Traffickers and terrorists have similar logistical needs in terms of materiel and the covert movement of goods, people, and money. Relationships between drug traffickers and terrorists can be mutually beneficial. Drug traffickers gain from access to terrorists' military skills and weapons supply; terrorists gain a source of revenue and expertise in illicit transfer and laundering of proceeds. Both bring corrupt officials whose services provide mutual benefits, such as greater access to fraudulent documents, including passports and customs papers. Drug traffickers can also gain considerable freedom of movement when they operate in conjunction with terrorists who control large amounts of territory ( Beers and Taylor 2002 ). This gives rise to the term  narcoterrorism —terrorist acts carried out by groups that are directly or indirectly involved in cultivating, manufacturing, transporting, or distributing illegal drugs.

   A number of terrorist groups use drug trafficking to further their political ends—overthrowing governments and imposing their worldview. “It is not particularly uncommon for terrorist groups to recruit some of their members among criminal elements, particularly among individuals who may have special skills or common criminals who contribute to its goals in instrumental, training, and other matters” ( Préfontaine and Dandurand 2004 , 16). Terrorist and drug-trafficking groups share some attributes, in particular organizational structure such as  compartmentalization  (see  Figure 9.2  on page 231). Terrorist groups and trafficking organizations often have similar requirements for moving people, money, materiel, and weapons across borders and often operate under a similar set of contingencies. The distinction between drug trafficking and terrorism is becoming increasingly blurred, and we see an overlapping, symbiotic relationship between terrorism, drugs, and organized crime ( Perl 2000 ).

FIGURE 9.1

Colombia, Center of the World's Cocaine Trafficking

   Taliban insurgents in Afghanistan, for example, have been using heroin to finance their efforts. The Taliban tax poppy farmers and the traders who collect opium paste from them for transport to labs where it is converted into heroin. Truckers pay a transit tariff when heroin is smuggled out of Afghanistan and drug trafficking organizations make large regular payments to the Quetta Shura, the Taliban's governing body ( Schmitt 2009 ). In Southeast Asia's Golden Triangle, there is a long-standing tradition of using heroin trafficking to support insurgencies.

   The Marxist-inspired Revolutionary Armed Forces of Colombia (FARC) raises funds through taxation of the drug trade. In return for cash payments, or possibly in exchange for weapons, some units protect cocaine laboratories and clandestine airstrips in southern Colombia. Some FARC units are involved in limited cocaine laboratory operations, and some are directly involved in local drug trafficking activities, such as controlling cocaine base markets.

Colombia

Colombians have been able to dominate the cocaine industry for a number of reasons. The President's Commission on Organized Crime (PCOC) ( 1986 ) notes, “Colombia is well-positioned both to receive coca from Peru and Bolivia and to export the processed drug to the United States by air or by sea [and] the country's vast central forests effectively conceal clandestine processing laboratories and air strips, which facilitate the traffic.” The Colombians “have a momentum by benefit of their early involvement in the cocaine trade” (78–79). In 1968, in an attempt to bolster its domestic economic performance, Colombia proudly established the Institute of Advanced Chemical Research in Bogotá, which started to train top-class chemists, who were later to find lucrative work in the employ of the Medellín and Cali cartels” ( Glenny 2008 , 245). Then there is a Colombian reputation for violence, which serves to maintain discipline and intimidate would-be competitors ( PCOC 1986 ). The propensity to use violence led to domination of potential Bolivian and Peruvian rivals in the cocaine business.

   Colombia is the only country in the world where the three main plant-based illegal drugs—cocaine, heroin, and marijuana—are produced in significant amounts ( Thoumi 2002 ). A nation of about 45 million persons, Colombia is the only South American country that has both Pacific and Caribbean coastlines (see  Figure 9.1 ). The high Andes divide the country into four regions, with most of Colombia's population concentrated in green valleys and mountain basins that lie between the Andes ranges; travel between populated areas is difficult ( Buckman 2004 ). It is a nation that has been torn by political strife, with civil wars in 1902 and 1948. “La Violencia,” as the civil war of 1948–1958 is known, cost the lives of about 300,000 people ( Riding 1987 ). It ended when the Liberals and the Conservatives formed the National Front, but several Marxist insurgencies continued to threaten the stability of the central government. Not only was murder frequent, but the methods that were used were often sadistic, such as the corte de corbata—the infamous “Colombian necktie”—in which the throat is cut longitudinally and the tongue is pulled through to hang like a tie. Another practice, no dejar la semilla (“don't leave the seed”), includes the castration of male victims and the execution of women and children ( Wolfgang and Ferracuti 1967 ).

FIGURE 9.2

Compartmentalized Organization

   For many decades, coca leaf was converted to cocaine base in Bolivia and Peru and smuggled by small aircraft or boats into Colombia, where it was refined into cocaine in jungle laboratories. Laboratories have relocated to cities far from cultivation sites to be closer to sources of  precursor  chemicals and because improved law enforcement methods have facilitated the detection of jungle laboratories. Precursor chemicals are usually manufactured in the United States and Germany; Panama and Mexico serve as major transit sources. Colombian cartels, using dummy companies and multiple suppliers, pay up to ten times the normal prices for these chemicals. Traffickers have also been stealing precursor shipments in transit from the point of entry into Colombia en route to a legitimate end-user.

   Some Colombian traffickers set up laboratories in other Latin American countries and even the United States in response to increased law enforcement in Colombia and the increasing cost of ether, sulfuric acid, and acetone in Colombia. Acetone, sulfuric acid, and ether are widely available for commercial purposes in the United States. While sulfuric acid and acetone have wide industrial use in Colombia, ether does not, and each kilo of cocaine requires seventeen liters of ether. The cost of these chemicals has increased as a result of controls imposed by the Colombian government on their importation and sale and of DEA's efforts to disrupt the supply of chemicals that are essential in the cocaine refinement process ( Hall 2000 ). Colombia is a relatively large country, and many regions have only a weak federal presence. “While Colombian authorities built suburbs and major highways between cities, they ignored vast sections of the country; much of rural Colombia is isolated by hilly, trackless terrain” ( Duzán 1994 , 63). Three steep mountain ranges run the length of Colombia, and impenetrable jungle covers the south: “The government didn't lose control of this half of Colombia; it never had it” ( Robinson 1998a , 39). The vacuum left by the central government has proved ideal for coca cultivation and cocaine manufacture because it left areas where only local officials had to be bribed, a cheaper and less risky action than bribery at the federal level ( Thoumi 1995 ). By 1998, Colombia had become the world's leading coca producer.

   Contesting the FARC for control of poppy- and coca-producing regions are right-wing militias that have proven to be more effective against the guerillas than government forces—and this has endeared them to elements of the population at risk. These militias have reinforced this support by building roads and schools in the areas from which they have driven the guerillas ( Forero 2001c ;  Guillermoprieto 2002 ).

   Pushed westward by Colombian military successes into jungle areas populated primarily by indigenous Indians, some former paramilitary and drug trafficking groups—the two often overlap—abandoned their ideological bent and have forged alliances with their former left-wing enemies. The same groups in other parts continue their violent struggles, but now the goal is control over the drug trade ( Romero 2009a ).

   Colombia-based cocaine trafficking groups in the United States continue to be organized around “cells” that operate within a given geographic area. Because these cells are based on family relationships or close friendships, outsiders who attempt to penetrate the cell run a high risk of arousing suspicion. Some cells specialize in a particular facet of the drug trade, such as cocaine transport, storage, wholesale distribution, or money laundering. Each cell, which may comprise ten or more individuals, operates with little or no knowledge about the other cells. In this way, should one of the cells be compromised, the operations of the other cells would not be endangered.  Figure 9.1  shows the basic structure of the organization used by drug cartels in Columbia, which can be divided in three components:

· ▸ Cell: Compartmentalization involves cells with about ten members, each operating independently—members of one cell typically do not know members of other cells. Operating within a geographic area, the head of each cell reports directly to a controller.

· ▸ Controller: Responsible for overall operations of the several cells within a region, the controller reports to central command via cell phone or Internet.

· ▸ Central Command: Located in a relatively safe haven, the central command oversees and coordinates operations through the controllers.

   A rigid top-down command and control structure is characteristic of these groups. The head of each cell reports to a regional director, who is responsible for the overall management of several cells. The regional director, in turn, reports directly to one of the top drug lords or his designate, based in Colombia. Trusted lieutenants of the organization in the United States have discretion in day-to-day operations, but ultimate authority rests with the leadership in Colombia ( Ledwith 2000 ).

   Traffickers from Colombia use state-of-the-art encryption devices to translate their communications into indecipherable code. This evolving technology presents a significant impediment to law enforcement investigations of criminal activities. In the past, the necessity for frequent communication between drug lords in Colombia and their surrogates in the United States made the drug-trafficking organizations vulnerable to law enforcement wiretaps. Now, however, through the use of encryption technology, the traffickers can protect their electronic business communications from law enforcement interception and hide information that could be used to build criminal cases against them.

   Colombian managers dispatched to the Dominican Republic and Puerto Rico operate these command and control centers and are responsible for overseeing drug trafficking in the region. Puerto Rico, a 110-mile-long island with the third busiest seaport in North America, is ideal for smugglers, who have fewer problems getting their goods to the United States because shipments from Puerto Rico are not searched by customs agents. Colombians direct networks of transporters that oversee the importation, storage, exportation, and wholesale distribution of cocaine destined for the continental United States. They have franchised to criminals from the Dominican Republic a portion of the midlevel wholesale cocaine and heroin trade on the East Coast of the United States.

   The Dominican traffickers operating in the United States, not the Colombians, are the ones who are subject to arrest, while the top-level Colombians control the organization with sophisticated telecommunications. This change in operations reduces profits somewhat for the syndicate leaders but reduces their exposure to U.S. law enforcement. If arrested, the Dominicans will have little damaging information that can be used against their Colombian masters. Reducing their exposure, together with sophisticated communications, puts the Colombian bosses closer to their goal of operating from a political, legal, and electronic sanctuary.

Heroin Trafficking in Colombia

Colombian entry into heroin is based on demographics. During the 1980s, the popularity of cocaine began to fade among urban professionals, and “cokeheads” tend to burn out after five years. With this dwindling consumer base, the Colombians expanded into Europe but with only limited success—heroin being the hard drug of choice and a market dominated by Pakistani and Turkish groups—and not until recently has cocaine use become popular and thus increased in Europe (The Transatlantic Cocaine Market 2011). So the Colombians diversified, importing poppy seeds, equipment, and expertise from Southwest Asia (Golden Crescent). By 1999, Colombians had become major heroin wholesalers, often selling cocaine and heroin to wholesalers as part of a package deal. Colombian market advantages include geographic proximity to the United States and established distribution networks. They required their Dominican cells in the United States to take a couple of kilos of heroin for every 100 kilos of cocaine to give out free samples to customers—and the strategy worked, creating an entirely new client base for heroin. The purity level of their heroin permits it to be prepared for smoking, ridding the product of its dirty needles and HIV reputation ( Brzezinski 2002 ). Smoking is a less efficient way of ingesting than intravenous use because a lot of the drug literally goes up in smoke. Therefore, only when it is relatively cheap and, therefore, plentiful will smoking heroin predominate.

   Since the 1980s, Colombia has become a leading poppy grower, and Colombians have become major heroin wholesalers. At the end of 1991, police raids in Colombia disclosed thousands of acres of poppy plants ( “Colombian Heroin May Be Increasing” 1991 ). On the mountain slopes of Colombia's Andean rain forests, guerrillas and drug traffickers grow significant crops. On the hillsides of a reservation in the southern Colombian state of Cauca, at an altitude of 9,000 feet, Guambiano Indians cultivate their most precious crop. Gum from their poppies brings about $115 a pound and represents the difference between food and hunger. Nine other states are known to have poppy plantations ( Tamayo 2001 ).

   By the end of the 1990s, Colombian heroin accounted for more than 50 percent of the drug smuggled into the United States. The high purity level of Colombian heroin—it passes through fewer hands from “the farm to the arm” than the Asian variety—enables ingestion by sniffing and smoking, methods that are much safer than injection, which is the only way to get a potent high with weaker versions of the drug. During the 1980s the Colombian drug lords relied heavily on organized groups from Mexico to transport cocaine into the United States after it was delivered to Mexico from Colombia. Currently, the greatest proportion of cocaine available in the United States is still entering the United States through Mexico. Using their skills as seasoned drug traffickers with a long tradition of polydrug smuggling, crime lords from Mexico soon established cocaine-trafficking routes and contacts. In the late 1980s, Colombia-based organizations, which had paid transporters from Mexico cash for their services, began to pay them in cocaine—in many cases up to half of the shipment. As a result the organizations from Mexico evolved from mere transporters of cocaine to major cocaine traffickers in their own right, and today they pose a grave threat to the United States.

   Mexican organized crime syndicates control the wholesale distribution of cocaine in the western half and the Midwest of the United States and they dominate the drug trade in the Northwestern United States ( National Drug Intelligence Center 2009h ,  2009a ). The dismantling of major Colombian cartels in Medellín and Cali created opportunities for their Mexican colleagues who began forging direct links with cocaine sources in Bolivia and Peru. In their weakened state, Colombians now have to compete with Mexican organizations for the U.S. market. Mexican organizations “are the greatest drug trafficking threat to the United States; they control most of the U.S. drug market and have established varied transportation routes, advanced communications capabilities, and strong affiliations with gangs in the United States” ( National Drug Intelligence Center 2009a , 45).

Mexico

Mexican drug trafficking organizations control most of the U.S. drug market and have established varied transportation routes, advanced communications capabilities, and strong affiliations with gangs in the United States, overseeing drug distribution in more than 230 U.S. cities. They are the only drug trafficking organizations operating in every region of the country ( National Drug Intelligence Center 2009a ,  2010 ,  2011 ).

   Mexico is a nation of more than 100 million people, 75 percent of who live in urban areas. Independence from Spanish rule in 1821 was followed by a series of revolutions, rigged elections, and general turmoil. There was a war with the United States in 1848 and a French invasion and occupation from 1863 to 1867. In still another violent overthrow, Porfirio Diaz came to power in 1876 and ruled Mexico for thirty-five years. Out of the revolution that ousted Diaz emerged Mexico's dominant political party, Partido Revolucionario Institucional (PRI; pronounced “pree”).

   For decades after its founding, the PRI “was a tool of successive presidents using authoritarian methods to insure one-party rule” ( Dillon 1999b , 1). The police forces—federal, state, and local—that evolved out of this atmosphere have been deployed not to protect but to control the population. Furthermore, police officers have been poorly paid, and it is understood that they can supplement their pittance with bribes as long as they remain loyal to the government ( Dillon 1996 ). The PRI ruled Mexico for more than seventy years without any strong opposition, during which time corruption became endemic. As a former governor of the Mexican state of Chihuahua stated: “If we put everyone who's corrupt in jail, who will close the door?” ( Aridjis 2012 )

   When it ruled Mexico as an elective dictatorship, the PRI “accommodated but regulated the drug cartels” ( Padgett 2009 , 39). The decline of the PRI and political reform in Mexico brought unintended consequences: In the wake of his election in 2006, President Felipe Calderón declared war on the drug cartels and dispatched the military in what has become an increasingly bloody campaign as the traffickers fought back ferociously. As Shirk ( 2010 ) notes, “Lacking a unified, overarching hierarchy of corrupt state officials to limit competition, the organization of drug trafficking became more fractionalized” and competitive. With the added effect of government counter-drug efforts, the result is “a more chaotic and unpredictable pattern of violent conflict among organized crime groups than Mexico has ever seen” (11).

   Free-market reforms and its gradual implementation pushed many ordinary Mexicans to find alternative employment. “As the global economy grew, so did a diversified and innovative network of illicit entrepreneurs, and drug trafficking presented the most lucrative of black market opportunities…. Although Mexico had been a longtime source of marijuana, opium, and synthetic drugs for the U.S. market, its rise as a transit point for cocaine created profitable new employment opportunities for the estimated 450,000 people who rely on drug trafficking as a significant source of income today” ( Shirk 2011 , 7). Despite political changes, Mexico remains in an economic crisis, crime has skyrocketed, and the criminal justice system is in an advanced stage of deterioration—more than 95 percent of violent crimes in Mexico go unsolved—the police are intimidated, corruption endemic, and human rights violations widespread ( Padgett 2011 ). “Torture by the authorities is so common in Mexico that it seemingly fails to shock anyone to whom it has not happened” ( Finnegan 2010 , 71).

The Economics of Cocaine

Mexico's Sinaloa Cartel can purchase a kilo of cocaine in the highlands of Colombia for about $2,000. As it makes its way north, the market value of that kilo increases. In Mexico, that kilo fetches more than $10,000. Across the U.S. border, that same kilo can sell for $30,000. At the retail per-gram level, it sells for as much as $100,000.

Source: Keefe 2012 , 37.

   “Mexican-based trafficking organizations control access to the U.S.-Mexico border, the primary gateway for moving the bulk of illicit drugs into the United States” ( National Drug Intelligence Center 2011 , 8). They do not expend resources in an attempt to control territory ( Molzahn, Ríos, and Shirk 2012 ). Instead, they “simultaneously use, or are competing for control of various smuggling corridors that they use to regulate drug flow across the border. The value they attach to controlling border access is demonstrated by the ferocity with which rival groups fight over control of key corridors, or ‘plazas’” ( National Drug Intelligence Center 2011 , 8).

   In 2011, Human Rights Watch accused the Mexican military of engaging in torture, forced disappearances, and extra-judicial killings in its war against organized crime. Corruption and intimidation extend into the media: journalists receive payoffs or threats and avoid offending politicians and the military, or probing the drug business ( Bowden 2011 ). Since 2007, almost seventy Mexican journalists have been murdered ( Padgett 2011 ).

   Mexicans distrust the police while fearing the traffickers, who have resorted to beheadings to terrorize the public. “Along with the widespread fear comes a certain respect. Big-time mobsters are treated like folk heroes in their home regions, their stories told and retold in popular songs” ( J. C. McKinley 2007 , 10). The popular culture of Mexico is infused with songs and ballads—known as narcocorridos—glamorizing drug trafficking ( Downes 2009 ). Major narcotraficantes are celebrated, along with their subculture of violence. Many songs contain references to an outlaw code of behavior, and narcocorrido music videos depict violence, including torture and the murder of police officers ( Dillon 1999a ). The songs are filled with unusually explicit lyrics about decapitations and torture, and praise for one drug gang in particular: the Sinaloa cartel and its bosses, Ismael “El Mayo” Zambada and Joaquin “El Chapo” Guzman In the Pacific seaside resort town of Mazatlán, in Sinaoloa State, home of the Sinaloa cartel, tourists can enjoy a “narco-tour.” Tourists—almost all are Mexicans from other parts of the country—pay about $15 an hour to visit the homes of narcotraficantes and scenes of some of their bloody shootouts ( Lacey 2009a ).

   Charles Bowden ( 2009 ) refers to two Mexicos. The first is where the Mexican president is fighting a valiant war on drugs, aided by the Mexican Army and $1.4 billion in U.S. aid. The second is where there is a war for control of drugs, where the police and the military fight for their share of the business. Even imprisonment does little to impede their drug business. Indeed, prisons often serve as a base of cartel operations: “For drug lords, flush with money, life on the inside is often the free-spirited existence they led outside. Inmates look up to them. Guards often become their employees” ( Lacey 2009c , 6). In 2009, guards at a northern Mexican prison allowed 53 dangerous inmates, including about a dozen who were drug cartel suspects, to walk out. Once outside, eight men wearing jackets with the federal police insignia escorted them to police cars with flashing lights. The incident was captured on video by prison security cameras ( Associated Press 2009a ). In 2010, it was disclosed that inmates in a Mexican prison, armed with weapons issued to prison guards, were allowed out at night to carry out drug trafficking-related executions (Malkin 2010).

   In the employ of the Gulf cartel—one of several operating in Mexico—is an assassination unit of former Mexican special forces (Grupo Aeromovil de Fuerzas Especiales) trained in the United States and known as “Los Zetas,” named after the radio call name of their original leader who was killed in 2002. In 2004, the unit's chief was captured after a gunfight with Mexican agents who found a cache of military-grade automatic weapons and grenades (McKinley 2004a). That same year, a well-organized jailbreak freed five suspected cartel gunman who were being held on murder charges (Reuters 2004a). Their leader, Heriberto Lazcano, 29, known as “El Verdugo” (the Executioner),” is reported to have fed victims to the lions and tigers he keeps on his ranches. Lazcano was part of an elite special forces unit sent to combat drug trafficking on the eastern border that, instead, began working for the Gulf cartel in the late 1990s. In place of their military pay of $700 a month, they are paid $15,000 a month. Their military discipline, training, arsenal, and wiretap capability make them a formidable organization that has expanded into ransom kidnapping and extortion from businesses ( Padgett 2005 ).

   The lethality of the Zetas has been strengthened by their recruitment of Mexican American teenagers, some as young as thirteen, who are trained for months on the use of assault rifles and hand-to-hand combat and placed in comfortable houses on both sides of the border. While awaiting assignments, youngsters receive a retainer of $500 a week and from $10,000 to $50,000 per assassination. There are also perks such as parties with attractive women and luxury cars for outstanding work ( McKinley 2009b ). “Los Zetas has since expanded beyond its enforcement and security services to become fully engaged in trafficking illicit drugs to the United States ( National Drug Intelligence Center 2009d , 9).

Los Zetas and the Sport of Kings

In 2012, after the arrest and indictment of Zetas in New Mexico and Oklahoma, the U.S, State Department warned Americans traveling in Mexico that they could become the subject of retaliatory violence. Those arrested are accused of laundering millions in drug profits through breeding and racing quarter horses in the United States. They are alleged to have moved drug cartel profits to José Treviño Morales and his brother Miguel, a Zeta enforcer known for dismembering victims while they are alive. José and his wife, who own a seventy-acre ranch in Oklahoma, were among those arrested; Miguel is a fugitive for whose capture the DEA has offered a $5 million reward. It is not unusual for Mexican breeders to move their operations to the United States where they do not have to fear competing for large purses.

   Treviño horses competed at Ruidoso Downs in New Mexico and won lucrative races, including the $1 million All American Futurity in 2010, considered the Kentucky Derby of quarter horses.

Source: G. Tbompson 2012 .

   In 2005, hours after being sworn in, a businessman who had volunteered to become Nuevo Laredo's police chief—no one else wanted the job—was assassinated by men firing assault rifles from an SUV. The federal government responded by sending in the military ( Jordon and Sullivan 2005 ). Later that year, federal authorities arrested fifteen Laredo police officers for abducting people on orders from the Gulf cartel (Iliff 2005). In 2008, gunmen killed the head of the federal organized crime division, and two weeks later the chief of the federal police. Mexican authorities subsequently charged six men with links to the Sinaloa cartel including the man who hired the shooter, a federal police officer ( McKinley 2008f ,  2008g ). “Mexico has never been particularly adept at bringing criminals to justice,” notes Lacey ( 2009e ), and “the drug war has made things worse. Investigators are now swamped with homicides and other drug crimes that they will never crack. On top of the standard obstacles—too little expertise, too much corruption—is one that seems to grow by the day: fear of becoming the next body on the street” (1).

   The Mexican military has been mobilized to combat the drug cartels, but critics claim the army is a major part of the problem: There is a history of collusion between the armed forces and drug traffickers and the military has been responsible for widespread human rights abuse ( Caputo 2009 ). Amnesty International, Human Rights Watch, Mexican human rights groups, as well as the U.S. Department of State, have accused the Mexican military of widespread human rights violations that include kidnappings and extra-legal killings ( Lacey 2009f ).

   Cartel militarization and the Mexican government's military response have resulted in fierce gun battles. Gunmen have refused to surrender and have ambushed soldiers and police officers. They have corrupted local police departments and assassinated honest police commanders. In 2008, after a violent gun battle with soldiers and police officers in Rio Bravo, Mexican authorities arrested three U.S. citizens, gunmen working for the Gulf cartel who had been recruited from across the border (McKinley 2008h). A few days later in Tijuana, government forces fought a three-hour battle with gunmen who used heavy machine guns and rocket-propelled grenades (McKinley 2008d, 2008e). The group acquired military-grade weapons, including assault weapons and ammunition, in the United States and smuggled them back into Mexico.

Guns, Guns, Guns

The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) traced 99,000 firearms recovered by law enforcement authorities in Mexico between 2007 and 2011. ATF found that more than 68,000 were from the United States. The data shows a trend in recovered and submitted crime guns from Mexico, a shift from pistols and revolvers to assault rifles with detachable magazines frequently used by drug trafficking organizations.

   At the end 2009, in a two-hour shootout, Mexican marines killed the wanted drug lord Arturo Beltran Leyva; six other traffickers and one marine were also killed. Several hours after the dead marine's mother attended his memorial service in Mexico City, where she received the Mexican flag covering her son's coffin, gunmen armed with assault rifles broke into the marine's home and killed his mother, his aunt, and two siblings ( Associated Press 2009c ).

   In 2009, after the arrest of a ranking member of La Familia Michoacána, a cultlike gang of methamphetamine traffickers noted for beheading enemies and headquartered in the southwestern state of Michoacán, a series of retaliatory attacks ensued resulting in the killing three federal officers and two soldiers. Several days later, the bodies of twelve military intelligence officers who were investigating La Familia were found bound, blindfolded, and tortured ( Malkin 2009 ;  “12 Mexican Intelligence Agents Tortured, Slain” 2009 ).

   In the early 1990s, the Mexicans struck a deal with the Colombians whose cocaine they were moving from Mexico into the United States on a contract basis: For every two kilograms of smuggled cocaine the Mexicans would keep one kilogram as payment in kind ( O'Brien and Greenburg 1996 ;  Wren 1996 ). Both sides benefited. The Colombians had an abundance of cocaine, and the Mexicans had a distribution network in the United States that they had previously used for heroin. This arrangement was aided by the North American Free Trade Act, which further opened the already porous borders between the United States and Mexico (See  Figure 9.3 ).

   Better organization and an extensive drug portfolio have enabled Mexican organizations to diversify by dividing operations into heroin, cocaine, marijuana, and now methamphetamine units. In 2012, Mexican authorities found fifteen tons of pure powdered methamphetamine at a ranch outside Guadalajara (Cave 2012).

   Although major international trafficking organizations have traditionally specialized in one substance—heroin or cocaine—in several cases commodity lines have become blurred: Colombians, historically cocaine traffickers, have become involved in the heroin business, while Mexicans, traditionally heroin traffickers, have become major cocaine dealers. The portfolio of Mexican traffickers includes marijuana that some observers believe has become their most lucrative product. Mexican traffickers have relocated many of their outdoor cannabis cultivation operations in Mexico from traditional growing areas to more remote locations in central and northern Mexico, primarily to reduce the risk of eradication and gain easier access to U.S. drug markets ( National Drug Intelligence Center 2009c ;  2009m ).

FIGURE 9.3

Mexico and Bordering States

   As opposed to the instability of the heroin and cocaine markets in the United States, marijuana retains its marketability and profitability. Mexican marijuana is transported to the United States in pickup trucks driven over a ramp that has been placed on border security fences, or though cross-border tunnels. Sometimes they simply throw bales of marijuana over the fence to be retrieved by confederates on the U.S. side. The September 11, 2001, terrorist attacks led to substantial tightening of the U.S.-Mexican border that affected marijuana smuggling routes. To avoid smuggling, cartels harvest on the U.S. side, where they lease fertile land such as vineyards or grow and harvest marijuana in national forests ( Moore 2009a ). As a result, plant growth hormones have been dumped into streams and the growing areas have become polluted with weed and bug sprays banned in the United States as well as rat poison used to keep animals away from the young plants ( Cone 2008 ).

Golden Triangle

The  Golden Triangle  of Southeast Asia encompasses approximately 150,000 square miles of forested highlands, including the western fringe of Laos, the four northern provinces of Thailand, and the northeastern parts of Myanmar, formerly Burma (see  Figure 9.4 ). These countries emerged from colonial rule with relatively weak central governments, their rural areas inhabited by bandits and paramilitary organizations. Colonial officials, particularly the French, used these organizations and indigenous tribes against various insurgent groups, particularly those that followed a Marxist ideology. As support for overseas colonies dwindled at home, French officials in Southeast Asia utilized the drug trade to finance their anti-insurgent efforts. Golden Triangle opium was shipped to Marseilles, where the Corsican underworld processed it into heroin for distribution in the United States—the “French Connection” discussed earlier.

FIGURE 9.4

Major Asian Opium Regions

   The French withdrew from Southeast Asia in 1955, and several years later the United States took up the struggle against Marxist groups there. The Vietnam War is part of this legacy. The U.S. Central Intelligence Agency (CIA) waged its own clandestine war. Again, heroin played a role, for many of the indigenous tribal groups that were organized by the CIA cultivated opium. In Laos and the former South Vietnam, corrupt governments were heavily involved in heroin trafficking, making the substance easily available to U.S. soldiers ( A. W. McCoy 1972 ,  1991 ). The tradition of using drugs to help finance military efforts continues as various ethnic groups press demands for autonomy from Myanmar. There are dozens of armed ethnic guerrilla groups, and each year sees the creation of one or two more. The most formidable, the United Wa State Army (USWA) controls the Wa State, a semi-autonomous region (Special Region No. 2) in Eastern Burma with a population of more than .5 million persons.

   The UWSA is the military wing of the United Wa State Party and was formed from the remnants of the Burmese Communist Party (BCP) in 1989. The BCP had received support from the People's Republic of China. After Beijing cut off this aid to improve relations with Myanmar, the BCP, following a long-established precedent in the region, went into the opium business. In 1989, its ethnic rank-and-file Wa tribesmen—fierce warriors whose ancestors were headhunters—rebelled, and the BCP folded as an armed force ( Haley 1990 ). Most Wa political groups reached an accommodation with the Myanmar ruling military junta, but one faction organized as the UWSA. Headquartered on the border of China's Yunnan Province, the UWSA uses trafficking in heroin—and more recently methamphetamine—as a means of funding efforts against Burmese control ( Witkin and Griffin 1994 ). Ironically, the Wa routinely executes anyone who is caught dealing heroin for local use ( Wren 1998b ).

   The UWSA has an estimated strength of 20,000 men, with another 30,000 reserves, well armed with ground-to-air missiles and modern communications equipment, mostly from China. The USWA maintains close ties with China and uneasy peace with Myanmar that has unsuccessfully pressed the Wa to disarm. The United States has offered $2 million for anyone who aids in the capture of the Wa drug kingpin who was born in China but has held leadership positions in the Wa government. According to the DEA, the UWSA is financed almost exclusively by drug trafficking, producing heroin and methamphetamine for distribution throughout Southeast Asia and other countries.

   Heroin manufactured in the Golden Triangle is smuggled into China's Yunnan Province and transported eastward to the coast and beyond. It is also smuggled through the Laos and Vietnam into the Guangxi Autonomous Region and Guangdong Province of China. Other important transit routes bring heroin from the Golden Triangle to major cities on the Southeast Asian peninsula, where it is sold in the illicit markets there or transported to other parts of the world. Golden Triangle heroin also feeds a sizable addict population in China. While Chinese authorities execute scores of drug traffickers and dealers each year, “they are not gaining the upper hand in the war against drug trafficking in the border areas, as more and more traffickers, many of them peasants from interior provinces of China hired as couriers (or “mules”), continue to cross the long and porous border” ( Chin and Zhang 2007 , 11).

Golden Crescent

The  Golden Crescent  of Southwest Asia includes Afghanistan, Pakistan, and parts of Iran (see  Figure 9.4 ). The region has limestone-rich soil, a climate and altitude that are ideal for poppy cultivation, and, like the Golden Triangle, a ready abundance of cheap labor for the labor-intensive production of opium, and the opium poppy grown in Afghanistan has a higher yield than that of Myanmar ( World Drug Report 2008 ). “What crude oil is to the Middle East, poppies are to Afghanistan” ( Powell 2007 , 31).

   Unlike Southeast Asia, Afghanistan's rugged terrain and the martial tradition of its tribes kept it free of colonialism. Western interest in this nation of about 27 million was limited until the Soviet invasion. The Pashtuns, a tribal group that populates Pakistan's Northwest Frontier Province, make up about 40 percent of the inhabitants of Afghanistan. The border dividing Pashtuns in Pakistan from their tribal brethren in Afghanistan was drawn by the British more than a century ago and is generally ignored; there are few border patrols in the region ( Ahmed-Ullah 2001 ).

   “Poppy growing is so uncontrolled that despite millions of aid dollars spent to train anti-drug forces and to help farmers grow other crops, Afghanistan is showing no signs of leaving its position as the world's biggest producer of opium” ( Gall 2006a , 4). It now accounts for more than 90 percent of global opium production. Afghan opium is processed into heroin in local laboratories or shipped to processing plants in Pakistan.

   Afghan heroin destined for Europe is frequently transported across the forbidding Margo desert. Heavily armed convoys traveling at high speeds move their supplies into Iran where thousands of police officers have been killed battling against heavily armed Afghan traffickers ( Gall 2005 ). The traffickers, equipped with antiaircraft missiles, night-vision goggles, and satellite telephones, are better armed than are their opponents in Iranian law enforcement.

   Turkey, which serves as a land bridge to markets in the West for heroin from the Golden Crescent, is fighting a similar battle. Kurdish separatists and Turkish criminal groups have important connections in the Western drug market. They move heroin across the highways of Turkey and into Europe where other criminal organizations, in particular Sicilian Mafia and Neapolitan Camorra groups, distribute the drug throughout the European market.

   In Pakistan, the typical poppy farmer lives in a semiautonomous northern tribal area outside the direct control of the central government in Islamabad. The Pakistani authorities have little control in these areas and must appeal to tribal leaders to move against the region's dozens of illegal opium-processing laboratories. In northwest Pakistan's Karakoram Mountains, an acre of poppies yields about a dozen kilos of opium gum; ten kilos of opium gum can be converted into one kilo of base morphine. The wholesaling is accomplished in lawless border towns such as Landi Kotal, which is about three miles from the Afghan border.

Arrested gunmen from Mexico's Sinaloa cartel and their weapons cache.

   The United States has pressured Pakistan to move against poppy cultivation, but the infusion of hundreds of thousands of Afghan tribesmen into Pakistan has made this difficult if not impossible. Tribesmen in Pakistan are now armed with rocket-propelled grenade launchers and automatic weapons to protect miles of poppy plants, pledging to die fighting rather than give up their best cash crop. Furthermore, there is a growing domestic market for heroin in Pakistan. While most poppies now grow on the Afghan side of the border and are shipped to Europe and North America in the form of powdered heroin, Pakistan's heroin-smoking population has grown, with estimates as high as 1 million users.

   The nations of Central Asia that surround Afghanistan, such as Tajikistan, have a predominantly young, rapidly growing, and poverty-stricken population. Add heroin to this mix, and you get an expanding addict population and drug organizations taking advantage of porous borders and easily bribed officials. “The drug business sustains up to 50 percent of the Tajik economy and props up its currency, if only because of the great number of people it employs” ( Orth 2002 , 168). For many of the warlords who are part of the post-Taliban Afghan government, heroin was the way they supported their armed followers. Islamic terrorist groups also operate in this region, and heroin provides them with an invaluable source of funds. And the connection between drugs and corruption reaches into the highest ranks of the Russian military ( Orth 2002 ).

   In the wake of the September 11, 2001, terrorist attacks, and U.S. military action against the Taliban government, the poppy once again became an indispensable crop in parts of Afghanistan. A pound of raw opium can be sold for $100 or more, over 100 times what a pound of fruits or vegetables will bring. By 2004, Afghanistan was producing more than three-fourths of the world's opium—more than 4,000 tons. That same year, the rush to grow poppy caused a glut on the market and a steep decline in its price ( Gall 2004 ;  Rohde 2004 ). Opium is so critical to the Afghan economy—roughly one third of the country's total gross national product—that U.S. officials have been reluctant to engage in an antidrug war that could conflict with efforts to combat terrorism ( Ives 2004 ;  Schmitt 2004 ;  Waldman 2004 ). America's military NATO allies in Afghanistan have been reluctant or unwilling to expand their mission into combating drug trafficking that they consider law enforcement ( Shanker 2008 ).

   Wealth from the drug trade has increased the power of regional local warlords, whose militias are a threat to the central government ( Schmitt 2004 ). But high-ranking members of the government are also profiting from the drug trade, as are terrorist groups. Supporters of the U.S.-backed Afghan government are profiting from drugs as are Taliban ( Gall 2003 ; Schweich 2008). In 2005, the United States criticized the Afghan leadership for the government's failure to curtail poppy cultivation. Antidrug efforts are hampered by a lack of alternative crops for impoverished farmers, and Taliban fighters have joined forces with drug smugglers against the government and Western troops ( Cloud and Gall 2005 ;  Schmitt 2006 ).

   By 2008, it was becoming obvious that poverty was not the driving force behind the expansion of poppy cultivation whose growth has largely been confined to the wealthiest parts of Afghanistan: “The starving farmer,” according to Schweich (2008), was a convenient myth that “allowed some European governments avoid involvement with the antidrug effort [and] the Taliban loved it because their propaganda campaign consisted of trotting out farmers whose fields had been eradicated and having them say that they were going to starve” (60). By 2009, it had become apparent that drug trafficking was sustaining the Taliban insurgency, and the U.S, announced that it was expanding military efforts in Afghanistan to include destruction of the opium crop ( Filkins 2009 ). Then, abruptly, late in June 2009, the U.S. announced a new policy: there would be a shift away from eradication of opium fields to interdicting drug supplies. Opium farmers would be aided in making a living through alternative crops while enforcement would focus on intercepting drugs being shipped out of the country ( Donadio 2009 ).

Taliban Heroin

Since the 1990s, Haji Bagcho headed a massive heroin operation that processed the drug in clandestine laboratories along Afghanistan's border region with Pakistan. He supplied more than 100,000 kilograms of heroin annually to more than twenty countries and used his millions in profit to support high-level Taliban commanders. In 2012, after being arrested and extradited from Afghanistan, Bagcho, was tried in federal in Washington, D.C., and received a life sentence.

Source: U.S. Drug Enforcement Administration press release.

Smuggling

Drugs are smuggled into the United States from both source and transshipment countries. Traffickers may use circuitous routes to avoid the suspicion that is normally generated by shipments from source countries. For example, cocaine might be shipped from Colombia to Africa and move from there to Europe and the United States as part of legitimate maritime cargo. Indeed, “traffickers are increasingly using Africa, both east and west, to smuggle cocaine from Latin America into Europe” ( Cocaine Trafficking in West Africa 2007 ;  Lacey 2006 , 4;  World Drug Report 2008 ). Guinea-Bissau, on the west coast of Africa, one of the poorest countries in the world, is a major transhipment point for Latin American traffickers moving drugs into Europe. There is a barely functioning police force and the country's military is deeply involved in the drug business—when the front-running candidate for president promised to crack down on the trade, the military staged a coup ( Collins 2012 ).

   Pleasure crafts and fishing vessels blend in with normal maritime traffic, and low-profile vessels made of wood or fiberglass and measuring up to forty feet in length, known as “go fasts” or “cigarette boats”, are difficult to spot and do not readily appear on radar. Smugglers also use aircraft, landing on isolated runways and even highways or dropping their cargo from the air. Motor vehicles use land routes across Canada and Mexico and onto Indian reservations bordering the United States. Often with the aid of Native American criminal groups, the traffickers then move the drugs across national borders into the United States for distribution ( Kershaw 2006 ;  National Drug Intelligence Center 2008a ). The Native American Tohono O'odham Nation reservation in Arizona straddles seventy-five miles of the U.S.-Mexican border and has emerged as a major transit point for drug smuggling, particularly marijuana, a bulky product that cannot be safely smuggled through official border checkpoints. The once placid reservation is now home to tribal members enticed by the financial rewards or fearful of declining the smuggler's offers ( Eckholm 2010 ). “In addition to the 43 legitimate border crossing points, the Southwest border includes thousands of miles of open desert, rugged mountains, the Rio Grande River, and maritime transit lanes into California and Texas” ( Office of National Drug Control Strategy 2009b , 13).

   The length and remoteness of the 1,933-mile-long border between Mexico and the United States make patrolling very difficult and facilitate the transportation of drugs into Texas, California, Arizona, and New Mexico. Drugs are also secreted in a variety of motor vehicles and smuggled past official border entry points. Private aircraft make use of hundreds of small airstrips that mark the U.S.-Mexican border and dozens of larger airstrips on the Yucatán Peninsula to move heroin north. Low-flying private aircraft—to avoid radar detection—use numerous privately owned “soft-surface” runways that dot the U.S.-Mexican border and dozens of larger airstrips on the Yucatán Peninsula to move drugs north. Ultralight aircraft are relatively inexpensive and portable and are capable of traveling in excess of seventy miles per hour. Also, it is often difficult for law enforcement officers to identify and interdict the aircraft before the operators deliver their contraband and return to Mexico.

   The United States spent $2.5 billion to build more than 600 miles of border fencing. In response, smugglers rewire ground sensors and extend custom-made ramps on trucks over the fence to drop drugs on the U.S. side, an operation that takes between two and four minutes to complete. Trucks and SUVs that pick up and transport the drugs stop their vehicles and use camouflage tarps whenever lookouts on nearby mountains radio—smugglers erected a string of communication towers—that border patrol agents are nearby. They may wait for days before resuming their journey ( Billeaud 2009 ).

   Drugs are secreted in a variety of motor vehicles and smuggled past official border entry points. More than 30 million personal vehicles and 12 million pedestrians cross the U.S.-Mexico border annually. Drug traffickers also transport drug shipments as airfreight or by courier aboard passenger flights (NDIC 2009). And there are “dope tunnels.”

   Since authorities began keeping records in 1990, dozens of dope tunnels have been found along the Mexican border with the United States—twenty-four were discovered in 2008 ( Office of National Drug Control Policy 2009b ). Most tunnels discovered by law enforcement officials over the past several years were in Arizona and California. Many tunnels were crudely built and were simple modifications of existing infrastructure, such as drainage systems. However, some were quite elaborate. In 2006, federal agents discovered a tunnel sixty feet below ground that stretched from a warehouse near the international airport in Tijuana to a vacant industrial building in Otay Mesa, California, about twenty miles southeast of downtown San Diego. The tunnel was outfitted with a concrete floor, electricity, lights, ventilation, and groundwater pumping systems. On the Mexican side, officials found a pulley system at the entrance and several thousand pounds of marijuana (Archibold 2006). In 2007, authorities uncovered a 1,300-foot tunnel some fifty feet below the ground linking Tecate, Mexico, with the city of the same name in California. The tunnel began in the floor of a building in Mexico and ended in a large shipping container in California. Passages were illuminated by fluorescent light, and carefully placed pumps kept the tunnel dry. “The neatly squared walls, carved through solid rock, bear the signs of engineering skill and professional drilling tools” (Archibold 2007, 18). In 2010, DEA agents in San Diego uncovered a sophisticated 600-yard underground cross-border tunnel. Approximately thirty tons of marijuana seized in the United States and Mexico have been linked to the tunnel. A crawlspace-sized passageway, the tunnel connected an Otay Mesa warehouse with a similar building in Tijuana, Mexico. The tunnel was equipped with railroad tracks and lighting and ventilation systems (DEA press release, November 3, 2010).

   Drug traffickers also have used submarines: An estimated 6,700 kilograms of cocaine was recovered from a submerged drug smuggling vessel in the Caribbean Sea. The vessel, a self-propelled semi-submersible vessel (SPSS) was interdicted by a U.S. Coast Guard cutter on September 30, 2011, in international waters of the Caribbean some 110 miles off of the coast of Honduras. A similar recovery operation earlier in the year yielded over 6,000 kilograms of cocaine from an interdicted SPSS that also sank in the Caribbean (FBI press release, October 28, 2011).

Swallowers

In 2012, U.S. Custom and Border Protection agents arrested a nineteen-year-old from New York City who arrived aboard a flight from Nigeria via Kenya and Zurich, Switzerland. Customs officers detected inconsistencies with his story about visiting his family in Nigeria. While being questioned, he asked to use the bathroom where he passed fifty-five thumb-sized heroin-filled pellets. Officers took him to a local hospital where he passed an additional thirty-one pellets, also filled with heroin. The eighty-six pellets had a combined weight of more than two pounds and an approximate street value of about $78,000. Several months later, a Nigerian woman was arrested at Washington Dulles International Airport after she was found to have swallowed a record 180 packs—about five pounds—of heroin with an approximate street value of $158,999.

Source:WTOP 2012;  Eames 2012 .

   Heroin traffickers use passengers and crew on commercial vessels, particularly cruise ships, to smuggle shipments into ports in South Florida. Cocaine and lesser amounts of South American heroin are moved into Puerto Rico on ferries from the Dominican Republic. In addition, Caribbean traffickers use noncommercial vessels to smuggle cocaine and marijuana into South Florida from the Bahamas and to Puerto Rico from the Dominican Republic and islands in the Lesser Antilles.

Domestic Drug Business

The farther down on the drug pipeline, the more likely it is that the trafficker will be involved in the sale of more than one substance. At the retail level, the seller may be a “walking drugstore.”

   Below the wholesale level, selling cocaine, heroin, and marijuana is an easy-entry business, requiring only a source and funds. Any variety of groups can come together to deal heroin, such as street gangs, in many urban areas. The enormous profits that accrue in the drug business are part of a criminal underworld in which violence is always an attendant reality. Drug transactions must be accomplished without recourse to the formal mechanisms of dispute resolution that are usually available in the world of legitimate business. This reality leads to the creation of private mechanisms of enforcement. The drug world is filled with heavily armed and dangerous individuals in the employ of the larger cartels, although even street-level operatives are often armed:

· Regular displays of violence are essential for preventing rip-offs by colleagues, customers, and professional holdup artists. Indeed, upward mobility in the underground economy of the street-dealing world requires a systematic and effective use of violence against one's colleagues, one's neighbors, and, to a certain extent, against oneself. Behavior that appears irrationally violent, “barbaric,” and ultimately self-destructive to the outsider, can be reinterpreted according to the logic of the underground economy as judicious public relations and long-term investment in one's ‘human capital development. ( Bourgois 1995 , 24)

   These private resources for violence serve to limit market entry, to ward off competitors and predatory criminals, and to maintain internal discipline and security within an organization. Goldstein ( 1985 ) reports that violence in the drug trade is sometimes the result of brand deception:

· Dealers mark an inferior quality heroin with a currently popular brand name. Users purchase the good heroin, use it, then repackage the bag with milk sugar for resale. The popular brand is purchased, the bag is “tapped,” and further diluted for resale.

·    These practices get the real dealers of the popular brand very upset. Their heroin starts to get a bad reputation on the streets and they lose sales. Purchasers of the phony bags may accost the real dealers, complaining about the poor quality and demanding their money back. The real dealers then seek out the purveyors of the phony bags. Threats, assaults, and/or homicides may ensue (497).

   In the drug business, as Goldstein ( 1985 ) notes, norm violations—for example, a street-level dealer failing to return enough money to his superior in a drug network—often result in violence. Violence almost invariably results from the robbery of a drug dealer. No dealer who wants to remain in the business can allow himself to be robbed without exacting vengeance. Death is also the punishment for a norm violation that, although serious, is nevertheless widespread in the drug business: informing. Informing can be the means of eliminating competition or exacting vengeance for the sale of poor-quality dope, but more often, informing results from an attempt to gain leniency from the criminal justice system.

   Occasionally, distinct patterns of injury can be recognized. For example, drug runners—teenagers who carry drugs and money between sellers and buyers—are seen in the emergency room with gunshot wounds to the legs and knees. A more vicious drug-related injury has emerged in the western part of the United States. In this injury, known as “pithing,” the victim's spinal cord is cut, and he or she is left alive but paraplegic ( De La Rosa, Lambert, and Gropper 1990 ).

   The domestic business of cocaine requires only a connection to a Colombian source and sufficient financing to initiate the first buy. Any variety of people several steps removed from the Colombian source are involved in the domestic cocaine business. Because the cocaine clientele is traditionally at least middle-income, distributors likewise tend to come from the (otherwise) respectable middle class. The popularity of crack, however, dramatically altered the drug market at the consumer level, in particular the age of many retailers. Inciardi and Pottieger ( 1991 ), both experienced drug researchers, were shocked by the youthfulness of crack dealers compared with those involved in the heroin business: “While both patterns ensnare youth in their formative years, crack dealers are astonishingly more involved in a drug-crime lifestyle at an alarmingly younger age” (269).

   In several areas of the United States, particularly in New York City and Los Angeles, the relatively stable neighborhood criminal organizations that once dominated the heroin and cocaine trade found new competitors: youthful crack dealers. Entry into the crack trade requires only a small investment since an ounce of cocaine can be converted to 2,500 milligrams of crack. Street gangs or groups of friends and relatives entered the market, often resulting in competition that touched off explosive violence involving the use of high-powered handguns and automatic weapons.

   The dramatic drop in homicides during the 1990s has been linked to the decline of crack ( Butterfield 1997 ). In New York City, according to Egan ( 1999c ), “in communities that used to have more open-air crack markets than grocery stores, where children grew up dodging crack vials and gunfire, the change from a decade ago is startling. On the surface, crack has disappeared from much of New York, taking with it the ragged and violent vignettes that were a routine part of street life” (1). New York's experience has been replicated in other major cities that had been plagued by the crack epidemic. In a dramatic change in attitude toward crack, “crackheads” became community pariahs. The remaining crack market has moved indoors, or dealers use cellular phones to arrange sales, typically to users who are considerably older than the adolescents who once made up the core of the crack scene.

   Some street gangs have also been expanding their organizations and drug markets to other states. Members of Los Angeles gangs, in particular the “Crips,” have moved into Seattle, Denver, Minneapolis, Oklahoma City, St. Louis, and Kansas City as well as smaller cities throughout California. Along with their smaller rival group, the “Bloods,” the Crips moved east with startling speed. “Neither gang is rigidly hierarchical. Both are broken up into loosely affiliated neighborhood groups called ‘sets,’ each with 30 to 100 members. Many gang members initially left Southern California to evade police. Others simply expanded the reach of crack by setting up branch operations in places where they visited friends or family members and discovered that the market was ripe” ( Witkin 1991 , 51).

   Participants in these drug networks, Mieczkowski ( 1986 ) notes, tend to be the most serious drug delinquents hired by adult or older adolescent street drug sellers as runners. They are organized into crews of three to twelve individuals, each member handling a small amount of drugs they receive “on credit” from a supplier. They are expected to return about 50 to 70 percent of the drug's street value. In addition to distributing drugs, youngsters may act as lookouts, recruit customers, and guard street sellers from customer-robbers. Their drug employment is not steady and interspersed with other crimes such as robbery and burglary. “A relatively small number of youngsters who sell drugs develop excellent entrepreneurial skills. Their older contacts come to trust them, and they parlay this trust to advance in the drug business. By the time they are 18 or 19 they can have several years of experience in drug sales, be bosses of their own crews, and handle more than $500,000 a year” ( Chaiken and Johnson 1988 , 12).

   Mieczkowski ( 1986 ) studied the activities of The Young Boys, Inc., a loosely organized retail heroin group in Detroit. At the center of their activities is a “crew boss,” who receives his supply of heroin from a drug syndicate lieutenant. The crew boss gives a consignment of heroin to each of his seven to twenty recruits, “runners,” typically African American males ranging in age from sixteen to twenty-three years old. Each runner then takes his station on a street adjacent to a public roadway to facilitate purchases from vehicles. To avoid rip-offs and robberies, each crew is guarded by armed men, including the crew boss himself. Runners reported earning about $160 for a workday lasting about ten hours.

   The net profits in heroin for most participants at the street level are rather modest. While dealers typically work long hours and subject themselves to substantial risk of violence and incarceration, their incomes generally range from $1,000 to $2,000 a month. Less successful participants eke out a living that rivals that of minimum wage. Many get involved to support their own drug habits, to supplement earnings from legitimate employment, or both. The sale of cocaine and crack is carried out by thousands of small-time operators who may dominate particular local markets—a public housing complex, city blocks, or simply street corners. Control is exercised through violence. Income is modest considering the dangers of death or imprisonment, and the sellers often work for less than minimum wage—for example, $30 a day for acting as a lookout, or fifty cents for each vial of crack sold. These may add up to $100 to $200 per week for long hours under unpleasant conditions without unemployment compensation, medical insurance, or any of the usual benefits of legitimate employment. A study in Washington, D.C., found that a majority of drug sellers in the sample did not sell drugs on a daily basis. Their median annual income was about $10,000. Those who sold daily earned about $3,600 a month ( Reuter, MacCoun, and Murphy 1990 ).

   At the retail level, sellers frequently deal several different drugs. Heroin dealers added cocaine to their portfolio when that substance started becoming popular at the end of the 1970s. Crack dealers reflected a shift in the market by also selling heroin ( Chitwood, Comerford, and Weatherby 1998 ).

   Chaiken and Johnson ( 1988 ) state that small drug sales are common among adult users and some adolescents distribute drugs without being involved in more serious criminal activity. These dealers sell drugs to adolescent friends and relatives less than once a month to support their own drug use, and “most of these adolescents do not consider these activities ‘serious crimes’” (10). They rarely have contact with criminal justice agencies: “Since these youths conceal their illicit behavior from most adults, and are likely to participate in many conventional activities with children their age, criminal justice practitioners can take little direct action to prevent occasional adolescent sellers from distributing drugs and recruiting new users” (11).

   Like more conventional consumer items, drugs sold at the street level often carry a name and/or logo to promote “brand loyalty.” “Among the more important marketing techniques are attractive packaging (stamps), name recognition (brand names), and consumer involvement and camaraderie around drug-consuming activities (product name contests). Moreover, product names … reflect strong, positive attributes and notions of success, strength, power, excitement, and wealth, encourage consumers to make symbolic connections with these products” ( Waterston 1993 , 117).

Open-Air Markets

Open-air markets represent the lowest level of the drug distribution network and operate in geographically well-defined areas at identifiable times so buyers and sellers can locate one another with ease. Some open-air markets are operated by groups with clear hierarchies and well-defined job functions. Others consist of fragmented and fluid systems populated by small groups of opportunistic entrepreneurs from a variety of backgrounds.

   The nature of open-air markets makes participants vulnerable to law enforcement and ripoffs. In response to the risks of law enforcement, open markets tend to transform into closed markets where sellers do business only with buyers they know. Intensive law enforcement can quickly transform open markets into closed ones.

   Drug dealing in open-air markets generates or contributes to a wide range of social disorder and drug-related crime in the surrounding community that can have a marked effect on the local residents' quality of life. However, simply arresting market participants will have little impact in reducing the size of the market or the amount of drugs consumed. This is especially true of low-level markets where if one dealer is arrested, there are, more than likely, several others to take their place. Moreover, drug markets can be highly responsive to enforcement efforts but the form of that response is sometimes an adaptation that leads to unintended consequences, including displacement or increased revenue for dealers with fewer competitors.

   Some researchers challenge the displacement thesis. They argue that police focus on a particular drug market does not cause dealers to “move around the corner.” Drug dealers, like legitimate entrepreneurs, such as auto dealers and restaurants, often find it advantageous to cluster. Clustering draws a larger customer base that, despite competition, profits all participants in the manner of a farmer's market. It also affords more protection than isolated dealing, the reason why buffalo herd, birds flock, and fish school. Focused police action, therefore, results in a diffusion benefit: drug trafficking becoming less profitable and smaller in size.

Source:Harocopos and Hough 2005;  Taniguchi, Rengert, and McCord 2009 .

   Colombians franchised to criminals from the Dominican Republic a portion of the midlevel wholesale cocaine and heroin trade on the East Coast of the United States. The Dominican trafficking groups, already firmly entrenched as low-level cocaine and heroin wholesalers in the larger northeastern cities, were uniquely placed to assume a far more significant role in this multibillion-dollar business. While Colombian groups remain in control of most of the sources of supply, Dominican organizations are also obtaining cocaine and heroin directly from Mexican sources at the Southwest Border and from sources in the Caribbean in order to lower purchase costs and increase profit margins. As a result of these relationships, Dominicans are also distributing marijuana and ice methamphetamine throughout the East Coast ( National Drug Intelligence Center 2009e ). The center of the Dominican wholesale drug trade is the uptown Manhattan neighborhood of Washington Heights. In recent years, some of the leaders have slipped out of New York and are running operations from their homeland, where corruption is endemic among airport officials and law enforcement.

   Dominicans have demonstrated the necessary talent for moving large amounts of heroin and crack cocaine. They generally provide top-quality uncut drugs at competitive prices, avoiding the common practice of diluting the product as it passes through the distribution chain. Often operating out of grocery stores, bars, and restaurants in Latino neighborhoods, they employ a variety of marketing gimmicks to move their product. In Philadelphia, they sold heroin packets with lottery tickets attached that a winner could use to claim an additional twelve packets.

   Jamaican organizations distribute marijuana in the New York metropolitan area. They obtain supplies from Mexican distributors, either locally or in southwestern drug markets. Additionally, some transport tons of marijuana from Jamaica aboard maritime conveyances. Jamaicans dominate marijuana distribution in sections of Manhattan, the Bronx, most of Queens (particularly the Jamaican section of southwestern Queens), northern Brooklyn, and sections of northern New Jersey ( National Drug Intelligence Center 2009f , 5–6).

   PCP, LSD, methamphetamine, and barbiturates are produced in domestic laboratories, and marijuana is grown in the United States and Canada. The people and groups that manufacture and traffic in these drugs are quite varied: white, rural, working- and middle-class individuals are as likely to be involved as any other racial or ethnic group. For example, there is little or no pattern to marijuana trafficking in the United States. It is an easy-entry business, and a number of relatives, friendship groups, and former military veterans have come together to “do marijuana.”

   In the rural Appalachia, a relatively high poverty rate contributes to an acceptance of cannabis cultivation as a source of income by many local residents Some residents in impoverished communities regard marijuana production as a necessary means of supplementing their low incomes. In many of these communities, cannabis cultivation is a multigenerational trade—young family members are introduced to the trade by older members who have produced marijuana for many years. Appalachia has a highly accessible transportation system, including major roadways that link it to many domestic drug markets (( National Drug Intelligence Center 2009f ), 2009).

   Production of methamphetamine has blossomed in parts of rural America. In Texas, labs are located in rural areas and usually set up and run by local residents similar to the operation of small-scale production and distribution of moonshine whiskey during the Prohibition Era ( Spence 1989 ). The number of meth labs seized in North Carolina has increased dramatically and about half have been in the rural mountain area in the western part of the state. Similar activity has been reported in rural communities in Tennessee and Georgia. In 2002, in the state of Washington's rural Snohomish County, there were more methamphetamine lab seizures than in New York, Pennsylvania, and New England combined ( Egan 2002 ). In farming communities, isolation and the easy availability of one of the drug's main ingredients, anhydrous ammonia, have spawned methamphetamine production ( Butterfield 2004b ).

   Outlaw chemists have been stealing anhydrous ammonia, normally used for fertilizer, for converting it into methamphetamine using Birch reduction; that is, the so-called “Nazi method.” 1  Anhydrous ammonia is stored as a liquid under pressure; however, it becomes a toxic gas when released to the environment. Anhydrous ammonia can be harmful to individuals who come into contact with it or inhale airborne concentrations of the gas. When stolen, the toxic gas can be unintentionally released, causing injuries to emergency responders, law enforcement personnel, the public, and the criminals themselves. While the labs are inexpensive for dealers to set up, the cost to the taxpayers for cleanup ranges from $5,000 to $100,000 per lab and is accomplished by crews wearing hazardous material suits for protection from fumes and deadly liquids ( Brevorka 2002 ;  Dewan and Brown 2009 ).

   According to federal data, there are tens of thousands of contaminated residences whose victims include low-income elderly people whose homes were used surreptitiously by relatives and landlords whose tenants leave them with toxic messes. There are hundreds of vacant and quarantined properties, particularly in Western and Southern states; some purchased by buyers who discovered the contamination as a result of illnesses caused by the toxic residue ( Dewan and Brown 2009 ).

   A report by the United Nations points to a change in the methamphetamine market: “Over the last few years, the methamphetamine market has moved from being a cottage-type industry (with many small-scale manufacturing operations) to more of a cocaine- or heroin-type market, characterized by a higher level of integration and involvement of organized crime groups that control the entire chain from the provision of precursors, to manufacture and trafficking of the end-product” (Amephetamines and Ecstasy2008, 17). In 2012, Mexican authorities seized 136 tons of methamphetamine precursor chemicals (phenylacetate and monomethylamine) from China at a port in the state of Michoacán. The prior week, thirty-six tons were seized in the port of Veracruz, also from China ( Looft 2012 ).

   The vast majority of MDMA (Ecstasy) consumed in the Unites States is produced in Europe—primarily the Netherlands and Belgium—and Canada; domestic production is limited. Overseas Ecstasy-trafficking organizations smuggle the drug in shipments of 10,000 or more tablets via express mail services, couriers aboard commercial airline flights, or air freight shipments from several major European cities to cities in the United States. While Ecstasy costs as little as 25 cents per pill to produce, wholesale prices range from $5 to $20, and retail prices range from $10 to $50 a dose. Traffickers in Ecstasy use brand names and logos as marketing tools and to distinguish their product from those of competitors. The logos are produced to coincide with holidays or special events. Among the more popular logos are butterflies, lightning bolts, and four-leaf clovers ( Office of National Drug Control Policy 2004e ).

   Fewer than a dozen chemists are believed to be manufacturing nearly all of the LSD available in the United States. Some have probably been operating since the 1960s. LSD manufacturers and traffickers can be separated into two groups. The first group, located in northern California, is composed of chemists (commonly referred to as “cooks”) and traffickers who work together in close association; typically, they are major producers who are capable of distributing LSD nationwide. The second group is made up of independent producers who, operating on a comparatively limited scale, can be found throughout the country; their production is intended for local consumption ( Drug Enforcement Administration n.d.a ).

   LSD chemists and top-echelon traffickers form an insiders' fraternity of sorts. They have remained at large because there are so few of them. Their exclusivity is not surprising, given that LSD synthesis is a difficult process to master. Although cooks need not be formally trained chemists, they must adhere to precise and complex production procedures. In instances in which the cook is not a chemist, the production recipe most likely was passed on by personal instruction from a formally trained chemist. At the highest levels of the traffic, at which LSD crystal is purchased in gram or multiple-gram quantities from wholesale sources of supply, it rarely is diluted with adulterants, a common practice with cocaine, heroin, and other illicit drugs. However, to prepare the crystal for production in retail dosage units, it must be diluted with binding agents or be dissolved and diluted in liquids. The dilution of LSD crystal typically follows a standard, predetermined recipe to ensure uniformity of the final product. Excessive dilution yields less potent dosage units that soon become unmarketable ( Drug Enforcement Administration n.d.b ).

Money Laundering

Money laundering is “to knowingly engage in a financial transaction with the proceeds of some unlawful activity with the intent of promoting or carrying on that unlawful activity or to conceal or disguise the nature, location, source, ownership, or control of these proceeds” ( Genzman 1988 , 1). According to the U.S. Treasury Department, money laundering is “the process by which criminals or criminal organizations seek to disguise the illicit nature of their proceeds by introducing them into the stream of legitimate commerce and finance” ( Motivans 2003 , 1).

   Drug traffickers operating at the upper levels of the business have a serious problem: What to do with the large amounts of cash the business is continually generating? Ever since Al Capone was imprisoned for income tax evasion, successful criminals have sought to launder their illegally secured money. Further complicating the problem is that this cash is frequently in small denominations. In some cases “laundering” may simply be an effort to secure hundred-dollar bills so that the sums of money are more easily handled (500 bills weigh about one pound).

   Modern financial systems permit criminals to instantly transfer millions of dollars through personal computers and satellite dishes. Money is laundered through currency exchange houses, stock brokerage houses, gold dealers, casinos, automobile dealerships, insurance companies, and trading companies. “The use of private banking facilities, offshore banking, free trade zones, wire systems, shell corporations, and trade financing all have the ability to mask illegal activities. The criminal's choice of money laundering vehicles is limited only by his or her creativity” ( U.S. Department of State 1999 , 3).

   Money laundering has been greatly facilitated by advances in banking technology. A customer can instruct his or her personal computer to direct a bank's computer to transfer money from a U.S. account to one in a foreign bank. The bank's computer then tells a banking clearinghouse that assists in the transfer—no person talks to another. While depositing more than $10,000 in cash into an account requires the filing of a Currency Transaction Report (CTR), the government receives more than 16 million such reports annually and is hopelessly behind in reviewing them (see  Figure 9.5 ). A CTR is required for each deposit, withdrawal, or exchange of currency or monetary instruments in excess of $10,000. It must be submitted to the IRS within fifteen days of the transaction. In 1984, tax amendments extended the reporting requirements to anyone who receives more than $10,000 in cash in the course of a trade or business. A Currency and Monetary Instrument Report (CMIR) must be filed for cash or certain monetary instruments exceeding $10,000 in value that enter or leave the United States. Federal Reserve regulations require banks to file a Suspicious Activity Report (SAR) when they suspect possible criminal wrongdoing in transactions.

FIGURE 9.5

Currency Transaction Report

   The Internet facilitates money laundering. A launderer establishes a company—the Abadinsky Computer Co.—offering high-end products over the Internet. The launderer purchases products from the Abadinsky Computer Co. over the Internet using credit cards. The Abadinsky Computer Co. invoices the credit card company that, in turn, forwards payment for the purchases. “The credit card company, the Internet service provider, the Internet invoicing service, and even the bank from which the illegal proceeds begin this process would likely have no reason to believe there was anything suspicious about the activity, since they each only see one part of it” (Financial Action Task Force on Money Laundering 2001, 4).

   Some criminals use casinos for the same purpose or to convert cash from small denominations to $100 bills. Casinos were made subject to the Bank Secrecy Act in 1970, so purchasing large amounts of chips while engaging in minimal gambling attracts unwanted casino attention. In response, collusive pairs began betting large amounts on both “red and black” or “odd and even” on roulette, or both with and against the bank in baccarat, or both the “pass line” or “come line” and the “don't pass line” or “don't come line” in craps. The “winning partner” then cashes in his or her chips and gets a casino check. Some will cash out chips multiple times a day at different times or at different windows/cages keeping the amount of each transaction below $10,000 to avoid the filing of a CTR.

   In some schemes, money launderers use dozens of persons (called “smurfs”) to convert cash into money orders and cashier's checks that do not specify payees or are made out to fictitious persons. Each transaction is held to less than $10,000 (called “structuring”) to avoid the need for a CTR. “Smurfing” has now been made a federal crime, and increased bank scrutiny has made tellers suspicious of cash transactions just under $10,000.

   Transactions involving the proceeds of drug trafficking often consist of large amounts of cash in small denominations. In such instances, the first step is to convert the small bills into hundreds—$1 million in $20 bills weighs 110 pounds; in $100 bills, it weighs only 22 pounds. To avoid IRS reporting requirements under the Bank Secrecy Act, transfers of cash to cashier's checks or $100 bills must take place in amounts under $10,000 or through banking officials who agree not to fill out a CTR. The cash can then be bulk-shipped over the U.S.-Mexican border where outgoing vehicles do not encounter the same scrutiny of those entering the United States (GAO 2010).

   The use of prepaid cash cards offers a compact, easily transportable way of moving money. Profits from crime are used to buy cards that can be used to connect to ATMs or for debit purposes. Cash is loaded onto the cards and then moved out of the country. The cards can be re-loaded over the Internet. Launderers typically use open system cards since they can be used at a myriad of stores, merchants, or automated teller machines within and outside the United States. These cards can be purchased on-line or in person. Open system cards may not require a bank account or face-to-face verification of the cardholder's identity. While anyone leaving the country with $10,000 or more in cash must submit a CMIR, cash cards are exempt. Some cards can process tens of thousands of dollars a month; load them in Texas with the proceeds of cocaine sales and collect the cash in local currency from an ATM in Colombia.

   Money laundering is facilitated by a variety of private banking operations, formal and informal. In the United States, commercial banks and securities firms may offer special banking services to wealthy persons who deposit $1 million or more. The bank assigns a private banker or broker-dealer in securities who facilitates complex wire transfers throughout the world and creates offshore accounts. An investment manager for a major securities firm in New York pled guilty in 2005 to laundering $15 million in drug proceeds generated by Mexico's Gulf cartel. Using a system known as layering, she coordinated the establishment of offshore corporations as well as offshore accounts in the names of third parties with the funds ultimately winding up back in the firm's accounts under the names of fictitious persons ( Berkeley 2002 ; Preston 2005c). As part of an overseas laundering scheme, a lawyer acting on behalf of a client creates a “paper” (or “boilerplate”) company in any one of a number of countries that have strict privacy statutes, such as Panama, which has about 400,000 registered offshore banks and companies The tiny Western and Pacific islands of Cook, the Marshalls, Nauru, Niue, Samoa, and Vanuatu have more than 18,000 registered banks and companies, Naura, with a population of about 12,000, has 450 banks registered to a single post office box. The U.K.-administered Cayman Islands, located south of Cuba, an easy flight from either Florida or Colombia, is 100 miles square and has a population of only 23,400. Yet there are about 600 banks and 20,000 registered companies on the Cayman Islands. The island's Georgetown financial district has the highest density of banks and fax machines in the world. Most banks are simply “plaques” or box offices—no vaults, tellers, or security guards—with transactions recorded by Cayman booking centers. Virtually anyone can “establish his or her own shell company for a few thousand dollars in legal fees, open a local bank account and, because the required disclosure is minimal and business operates behind a wall of strict secrecy, no one need know about the company or what funds are stashed there.

   The funds to be laundered are transferred physically or wired to the company's account in a local bank. The company then transfers the money to the local branch of a large international bank. The paper company is then able to borrow money from the United States (or any other) branch of this bank, using the overseas deposit as security. Or an employment contract is set up between the launderer and his or her “paper” company for an imaginary service for which payments are made to the launderer. In some cases, the lawyer may also establish a “boilerplate bank”—like the company, this is a shell. Not only does the criminal get his money laundered, but he also earns a tax write-off for the interest on the loan. Under the Bank Secrecy Act, wiring or physically transporting cash or other financial instruments out of the country in excess of $10,000 must be reported to the Customs Service. Once the money is out of the United States, however, it may be impossible for the IRS to trace it. In some schemes, the money is returned to the United States or other destination via the purchase of life insurance policies from the British Isle of Man, a center for international insurance firms. The policies frequently taken out in the name of relatives are then cashed out prematurely, the 25 percent penalty being part of the cost of the operation.

   Trade-based money laundering (TBML) involves use of the international trade system to disguise illicit proceeds to make it appear as legitimate. TBML can be accomplished through the use of informal banking systems such as the Black Market Peso Exchange (BMPE), in which one or more “peso brokers” serve as middlemen between, on one hand, drug traffickers who control massive quantities of drug cash in the United States, and, on the other, companies and individuals in Colombia who wish to purchase U.S. dollars outside the legitimate Colombian banking system so that they can, among other things, avoid the payment of taxes, import duties, and transaction fees owed to the Colombian government. Transactions are verbal, without any paper trail, and the disconnection between the peso transactions (which generally all occur in Colombia) and the dollar transactions (which generally all occur outside Colombia) make discovery of the money laundering by international law enforcement extremely difficult. Because of these inherent advantages, the BMPE system has become one of the primary methods by which Colombian traffickers launder their illicit funds (Drug Enforcement Administration 2004).

   More stringent federal laws against money laundering, along with anti-money laundering measures adopted by traditional financial institutions, have forced criminal organizations to shift the movement of their illicit proceeds outside of the established financial industry. To avoid scrutiny of law enforcement, criminals smuggle bulk cash into, out of, and through the United States.

   Criminals employ nontraditional methods to move funds, such as the chop and hawala. The chop is in effect a negotiable instrument that can be cashed in Chinese gold shops or trading houses in many countries. The value and identity of the holder of the chop is a secret between the parties. “The form of chop varies from transaction to transaction and is difficult to identify. In effect, the chop system allows money to be transferred from country to country instantaneously and anonymously” ( Chaiken 1991 , 495). For example, $100,000 in cash is deposited in a San Francisco Chinatown gold shop in return for a chop. The chop is sent by courier to Hong Kong where the gold shop's associate, usually a relative, gives $100,000 dollars minus a transaction fee to the possessor of chop.

   Another informal system, the hawala, is similar to the modern practice of “wiring money,” was the primary money transfer mechanism used in South Asia prior to the introduction of Western banking. “Hawala operates on trust and connections (‘trust’ is one of the several meanings associated with the word ‘hawala’). Customers trust hawala ‘bankers’ (known as hawaladars) who use their connections to facilitate money movement worldwide. Hawala transfers take place with little, if any, paper trail, and, when records are kept, they are usually kept in code” ( U.S. Department of State 1999 , 22). In Pakistan, for example, $100,000 (plus a transaction fee) is given to a hawaladar who provides a code term. Via the Internet, the hawalader informs his broker in the Cayman Islands, where someone who provides the code term is given $100,000 to deposit in an island account.

   In both systems, money is never actually moved, and periodically brokers balance their respective transactions, usually by wire transfers using goods and invoices as a cover. In the United States, there are an estimated 20,000 informal remittance businesses working out of a variety of convenience stores, restaurants, and small shops whose owners speak languages unfamiliar to Westerners such as Arabic, Urdu, Hindu, and a variety of Chinese dialects ( Freedman 2005 ).

   Money laundering is facilitated through the use of digital currency, privately owned online payment systems that allow international payments denominated in the standard weights for gold and other precious metals. While digital currency transactions can be traced back to an individual's computer, proxy servers and anonymity networks protect a person's identity by obscuring the unique IP (Internet protocol) address as well as the individuals' true location, And mobile payments conducted from anonymous prepaid cellular devices may be impossible to trace to an individual. After a single transaction, the device can be destroyed to prevent forensic analysis. Digital currency account holders may also use public Internet terminals or even “hijacked” wireless Internet connections to access their digital currency accounts, causing transactions to appear to originate with the unsuspecting Internet subscriber. Users of digital currency may encrypt their transmissions to conceal communications between individuals, making law enforcement scrutiny more difficult ( NDIC 2008b ).

   Our examination of the business of illegal drugs provides a framework for understanding the problems that confront law enforcement officials who are trying to constrain trafficking in dangerous drugs, the topic of the next chapter.

Chapter Summary

· 1. Appreciate that the law of supply and demand governs the illegal drug market:

· • Only the law of supply and demand governs drug trafficking and the business shares some elements with the business of selling legal products: lots of working capital, steady supplies of raw materials, sophisticated manufacturing facilities, reliable shipping contractors, and wholesale distributors.

· • At the manufacturing and importation levels, the drug business is usually concentrated among a relatively few people who head major trafficking organizations; at the retail level, it is filled with a large, fluctuating, and open-ended number of dealers and consumers.

· 2. Know the connection between drug trafficking and terrorism:

· • Relationships between drug traffickers and terrorists can be mutually beneficial and a number of terrorist groups use drug trafficking to further their political ends.

· • In the Far East, Middle East, and Latin America drug trafficking has been used to support insurgencies.

· 3. Understand why Colombia, Mexico, the Golden Triangle, and the Golden Crescent are the source of most of the world's illegal drugs:

· • Mexican and Colombian organizations maintain control of their workers through highly compartmentalized cell structures that separate production, shipment, distribution, money laundering, communications, security, and recruitment.

· • Colombia is the only country in the world where the three main plant-based illegal drugs—cocaine, heroin, and marijuana—are produced in significant amounts.

· • Colombians dominate the cocaine industry because of the country's geography, momentum gained by early involvement in the cocaine trade, and a reputation for violence.

· • With market advantages that include geographic proximity to the United States and established distribution networks, by 1999, Colombians had become major heroin wholesalers.

· • Although originally business partners, Colombians now have to compete with Mexican organizations for the U.S. market.

· • Mexico-based organizations are the only drug traffickers operating in every region of the United States.

· • Mexican trafficking organizations grew powerful amidst a culture of political corruption.

· • Violence between Mexican trafficking organizations is usually the result of fighting to control of key corridors, or “plazas” into the United States.

· • In the Golden Triangle, the tradition of using drugs to help finance military efforts continues as various ethnic groups press demands for autonomy from Myanmar.

· • Like the Golden Triangle, drug trafficking has traditionally supported tribal feuds and insurgencies in the Golden Crescent.

· • The efforts of the United States to deal with drug trafficking in Afghanistan have been compromised by efforts to deal with the Taliban.

· 4. Know the many ways to smuggle drugs into the United States:

· • The length and remoteness of the 1,933-mile-long border between Mexico and the United States make patrolling very difficult and facilitates drug smuggling.

· • Mexican drug traffickers have proven adept at overcoming efforts to thwart drug smuggling.

· • Drugs are also smuggled by “swallowers.”

· 5. Understand the persons and groups that operate at the retail level of drug trafficking:

· • The farther down on the drug pipeline, the more likely it is that the trafficker will be involved in the sale of more than one substance.

· • Drug transactions must be accomplished without recourse to the formal mechanisms of dispute resolution that are usually available in the world of legitimate business.

· • While street dealers typically work long hours and subject themselves to substantial risk of violence and incarceration, net profits for most are rather modest.

· 6. Appreciate why rural areas have become hospitable to marijuana cultivation and methamphetamine production:

· • The availability of remote spots provide “meth labs” with the isolation they require.

· • Farmlands provide fertile soil for marijuana.

· 7. Know how and why upper-level drug traffickers engage in money laundering:

· • Money laundering is to knowingly engage in a financial transaction with the proceeds of some unlawful activity with the intent of promoting or carrying on that unlawful activity or to conceal or disguise the nature, location, source, ownership, or control of these proceeds.

· • Money laundering can be accomplished in a wide variety of ways.

· • Financial institutions are required to file a Currency Transaction Report (CTR) for transactions in excess of $10,000 and to file a Suspicious Activity Report (SAR) when money laundering is suspected.

Review Questions

· 1. What does drug trafficking have in common with the business of selling legal products?

· 2. How did the demise of the French Connection affect the drug business?

· 3. How does the leadership of major trafficking organizations maintain tight control of their workers?

· 4. What are the advantages of compartmentalization for drug traffickers?

· 5. How can ties between drug traffickers and terrorists be mutually beneficial?

· 6. Why have Colombians been able to dominate the cocaine industry?

· 7. What led to Colombian entry into the heroin business?

· 8. Originally business partners, why do Colombians now have to compete with Mexican organizations for the U.S. market?

· 9. What is the cause of much of the violence between Mexican trafficking organizations?

· 10. Why is marijuana especially attractive to Mexican-based traffickers?

· 11. What is the connection between the Vietnam War and drug trafficking in the Golden Triangle?

· 12. Why do the Golden Triangle and Golden Crescent areas have a tradition of heroin trafficking?

· 13. Why have efforts of the United States to deal with heroin trafficking in Afghanistan been compromised?

· 14. Why are drug transactions so dangerous?

· 15. Why was the crack business so violent?

· 16. Why, despite low profit to risk ratios, do young men persist in the street-level drug business?

· 17. What are the conflicting views of the effectiveness of law enforcement efforts against “Open Air Drug Markets”?

· 18. Why is it so expensive to clean up methamphetamine labs?

· 19. Why do major drug traffickers engage in money laundering?

· 20. What is the purpose of a Currency Transaction Report (CTR)?

· 21. What is the responsibility of a financial institution when money laundering is suspected?

· 22. What are the ways in which money laundering can be accomplished?

CHAPTER 10 DRUG LAWS AND LAW ENFORCEMENT

Emblem of the U.S. Drug Enforcement Administration

After reading this chapter, you will:

· ▸ Appreciate that the single most important factor in drug use is degree of access

· ▸ Know that drug law enforcement is constrained by constitutional requirements, jurisdictional limitations, and corruption

· ▸ Know the federal agencies responsible for combating drug trafficking

· ▸ Understand the three categories of street-level drug enforcement

Drug “Enforcement”

At a police corruption trial, the ex-undercover NYPD officer testified that detectives were paid extra overtime for heroin and cocaine arrests: two-hours overtime pay per arrest. The officers on trial are accused of “flaking” suspects; that is, planting drugs on innocent victims. Drugs were skimmed from legitimate seizures before being inventoried for the purpose of flaking. The witness testified that he was socialized into this practice on the first day he was assigned to undercover drug work in Brooklyn. The cops he worked with routinely diverted funds for drug buys to personal use.

Source: Marzulli, Parascandola, and McShane 2011 .

“  This year [2009] marks the 40th anniversary of President Richard Nixon's start of the war on drugs, and it now appears that drugs have won.

—Nicholas D. Kristoff ( 2009 , 10)

“The most important precipitating factor in narcotic addiction is degree of access to narcotic drugs” ( Ausubel 1980 , 4), an assertion that is supported by research into heroin consumption ( Anglin 1988 ). This is why drug use is higher in the inner city than in the suburbs and why the incidence of illegal drug use in the United States approached the zero level during World War II. This also helps explain the relatively high level of drug abuse among physicians, in particular, anesthesiologists whose specialty offers ready access to fentanyl ( McDougall 2006 ). Research indicates that adolescent use of alcohol, cigarettes, and marijuana is related to access, hence the rationale for efforts aimed at imposing barriers to access ( Steen 2010 ). “Thus, no matter how great the cultural attitudinal tolerance for addictive practices is, or how strong individual personality predispositions are, nobody can become addicted to narcotic drugs without access to them. Hence the logic of a law enforcement component in prevention” ( Ausubel 1980 , 4).

   If drug use is seen as based on some combination of susceptibility and availability—“that drug abuse occurs when a prone individual is exposed to a high level of availability” ( R. S. Smart 1980 , 46)—it follows that a considerable reduction in availability can reduce drug use. That is, of course, if we discount the use of alcohol and tobacco, and the possibility—or probability—that people unable to secure their preferred substance will switch to alcohol.

   Availability also involves questions of cost. At some point, then, the cost of purchasing a drug can reduce to near zero its availability to potential abusers, and law enforcement efforts can affect the cost of illegal drugs.

   Before we can examine the strategies and techniques that law enforcement agencies use to deal with drug trafficking and to reduce the availability of drugs, we need to consider three issues that severely constrain law enforcement in general and drug law enforcement in particular: constitutional restraints, jurisdictional limitations, and corruption.

Constitutional Restraints

Law enforcement agencies in the United States operate under significant constraints written into the U.S. Constitution, generally referred to as due process—literally meaning the process that is due a person before something disadvantageous can be done to him or her. Due process restrains government from arbitrarily depriving a person of life, liberty, or property. There is an inherent tension between society's desire for security and safety and the value we place on liberty. Packer ( 1968 ) refers to this as a conflict between two conceptual models of criminal justice: crime control and due process.

   Due process, while it protects individual liberty, also benefits the criminal population by guaranteeing the right to remain silent (Fifth Amendment), the right to counsel (Sixth Amendment), the right to be tried speedily by an impartial jury (Sixth Amendment), and the right to confront witnesses (Sixth Amendment). The Fourth Amendment and the exclusionary rule are particularly important for drug law enforcement.

The Fourth Amendment and the Exclusionary Rule

The Fourth Amendment of the U.S. Constitution guarantees that “the right of the people to be secure in their persons, houses, papers and effects, against unreasonable searches and seizures shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.” In practice, information sufficient to justify a search warrant in drug cases is difficult to obtain; in contrast to such conventional crimes as robbery and burglary, there is an absence of innocent victims who will report the crime in drug cases. The exclusionary rule is the court's way of enforcing the Fourth Amendment; it provides that evidence that is obtained in violation of the Fourth Amendment cannot be entered as evidence in a criminal trial (Weeks v. United States, 232 U.S. 383, 1914; Mapp v. Ohio, 357 U.S. 643, 1961), although there are a number of exceptions that are beyond the scope of this book. The purpose of the exclusionary rule is to control the behavior of law enforcement agents, for example, making drug enforcement efforts that violate the Constitution not worth the effort.

   To respond effectively to drug trafficking, law enforcement officials require information about the activities of suspected traffickers. The Fourth Amendment and Title III of the Omnibus Crime Control and Safe Streets Act of 1968 (18 U.S.C. Section 2510-520) place restraints on how the government can secure this information. Thus, to surreptitiously intercept conversations by wiretapping telephones or using electronic devices (“bugging”), officials must secure a court order that, like a search warrant, must be based on information that is sufficient to meet the legal standard of probable cause. When an order to intercept electronic communications is secured (generally referred to as a “Title III”), it is quite limited, requires extensive documentation, and demands that the people whose communications are being intercepted be notified after the order expires. These requirements make electronic surveillance expensive, in terms of personnel hours expended, and difficult to accomplish properly.

   The supervision of drug law enforcement agents is also difficult because they typically operate covertly or undercover. This means that “legal control over agents is problematic, and the circumstances of arrest are often such that there is a great temptation to perjury, violation of the exclusionary rule, misuse of informants, discretionary dropping, overlooking and altering charges, and other violations of procedural and/or legal rules” ( J. Williams, Redlinger, and Manning 1979 , 6). The greater the pressure on law enforcement officers “to do something about drugs,” the greater is the temptation to avoid the significant constraints of due process and take unlawful (though often effective) shortcuts.

Jurisdictional Limitations

The U.S. Constitution provides for a form of government in which powers are diffused horizontally and vertically: three branches—legislative, judicial, and executive—and four levels—federal, state, county, and municipal—of government ( Figure 10.1 ). Although each level of government has responsibilities for responding to drug abuse and drug trafficking, there is little or no coordination among them. Each level responds to the problem of drugs independently of the others. Federalism was part of a deliberate design to help protect us against tyranny; unfortunately, it also provides us with a level of inefficiency that significantly handicaps efforts to curtail drug trafficking.

FIGURE 10.1

Governmental Complexity

   On the federal level, a host of executive branch agencies (to be examined later), ranging from the military to the Federal Bureau of Investigation (FBI), are responsible for combating drug trafficking. The separate federal judicial system is responsible for trying drug cases, and the legislative branch is responsible for enacting drug legislation and allocating funds for federal drug law enforcement efforts. At the local level are about 20,000 police agencies. Each state has state-level drug law enforcement agents, a state police or similar agency, and agencies that manage prisons and the parole system (if one exists). County government is usually responsible for prosecuting defendants, and a county-level agency, usually the sheriff, is responsible for operating jails. The county may also have a police department with drug law enforcement responsibilities under, or independent of, the sheriff's office, and almost every municipality has a police department whose officers enforce drug laws. Each of these levels of government has taxing authority and allocates resources with little or no consultation with other levels of government. The sum total is a degree of inefficiency surpassing that of most other democratic nations.

   U.S. efforts against drug trafficking are also limited by national boundaries: Cocaine and heroin originate where U.S. law enforcement has no jurisdiction. The Bureau of International Narcotics Matters, which is part of the State Department, has primary responsibility for coordinating international programs and gaining the cooperation of foreign governments in antidrug efforts. But the bureau has no authority to force governments to act in a manner that is beneficial to U.S. efforts in dealing with cocaine or heroin. Sciolino (1988) reports that the bureau “has little influence even within the [State] department. Foreign Service officers readily admit that they try to avoid drug-enforcement assignments because they generally do not result in promotions” (E3). The State Department also collects intelligence on policy-level international narcotics developments, while the Central Intelligence Agency (CIA) collects strategic narcotics intelligence and is responsible for coordinating foreign intelligence on narcotics. The CIA, however, has often protected drug traffickers who have provided useful foreign intelligence. U.S. efforts against drug trafficking are often sacrificed to foreign policy ( Sciolino and Engelberg 1988 ).

International Efforts

In 1988, the International Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances was adopted in Vienna, Austria, with two main purposes:

· First, to establish an internationally recognized set of offenses relating to drug trafficking that are to be criminalized under the domestic law of the parties to the convention; and second, to create a framework for international cooperation to enhance the prospect that traffickers and others who profit from trafficking will be brought to justice.

·    The Convention focuses on the eradication of drugs and drug-producing laboratories; the international transportation of precursor chemicals used to produce illegal drugs; the tracing of laundered drug trade profits back to the drug cartels; and the worldwide extradition of drug criminals so that they can have no safe havens. Significantly, the Convention obligates parties to make money laundering an extraditable offense, to afford the widest measure of international mutual legal assistance in judicial proceedings, and to cooperate closely to enhance the effectiveness of law enforcement actions to suppress narcotics trafficking and related offenses. ( Thornburgh 1989 , 59)

   In 1994, President Bill Clinton signed legislation authorizing the president to provide assistance for the prevention and suppression of international drug trafficking and money laundering. While international law (multinational treaties) provides the basis for eradicating illicit poppy and coca cultivation, adherence to treaties depends on a level of cooperation that is often sacrificed on the altar of domestic economic and political realities (discussed in  Chapter 8 ). Under treaties, coca- and poppy-producing countries are to limit their cultivation acreage to a level that is in line with legitimate world needs. Strict controls over growers require them to deliver their crops to a government monopoly to prevent diversion to the black market. Crops growing wild are to be destroyed. The price paid by the government, however, is not competitive with that offered by traffickers, and the illegal diversion of coca or opium is the only significant source of cash for many peasant growers, whose standard of living is already marginal. Attempts to substitute other cash crops have met with only limited success because such programs cannot challenge the reality of the marketplace. As noted in  Chapter 9 , coca and poppies are grown in regions where governments often have only nominal control.

   Jurisdictional limitations, however, can sometimes overcome constitutional restrictions. For example, because the Bill of Rights applies only to actions of the U.S. government, the Fourth Amendment and exclusionary rule do not govern seizures in foreign countries by those nations' police. This holds even when the evidence that is seized is from U.S. citizens; thus, it would be admissible in a U.S. court ( Anderson 1992 ). Furthermore, the Supreme Court has held that constitutional protections do not obtain in U.S. government actions against foreign nationals on foreign soil. In United States v. Verdugo Urquidez(110 S.Ct. 1056 1990), a Mexican national who was suspected in the 1985 torture-murder of a Drug Enforcement Administration (DEA) agent was apprehended by Mexican police on a U.S. warrant and turned over to U.S. marshals at the California border. At the request of the DEA, Mexican police, without a warrant, searched the fugitive's two residences and seized incriminating documents, which were turned over to the DEA. The evidence was ruled admissible.

   In a 1992 ruling on another case involving the murder of a DEA agent, the Supreme Court ruled that kidnapping a suspect on foreign soil does not prevent the suspect from being tried in the United States. In this case (United States v. Alvarez Machain, 504 U.S.), Mexican bounty hunters kidnapped a medical doctor and took him to El Paso; they were paid $20,000 and given the right to settle with their families in the United States. The Mexican government reacted with outrage to the decision.

Corruption

In  Chapter 9 , we examined the complex world of drug trafficking and the enormous profits that accrue to many of those involved. The easy availability of large sums of money and the clandestine nature of the business make drug law enforcement vulnerable to corruption.

   Two basic strategies are available to law enforcement agencies—reactive and proactive—and many use a combination of both. Reactive law enforcement has its parallel in firefighting: Firefighters remain in their fire stations, equipment at the ready, until they get a call for service. Reactive law enforcement encourages citizens to report crimes; the agency will then respond to the reports. This type of law enforcement is used for dealing with such conventional criminal behavior as murder, rape, assault, robbery, burglary, and theft, which are likely to be reported to the police. (It should be noted, however, that with the exception of murder and auto theft, studies indicate that most crimes of these types are notreported to the police.) Proactive law enforcement requires officers or agents to seek out indications of criminal behavior, always a necessity when the criminal violation includes victim participation (e.g., gambling, prostitution, and drugs). These crimes are often described as consensual or “victimless,” although they clearly have victims who are unlikely to report the crime to the police. The problem of corruption is in part tied to the proactive strategy.

Corruption in the Headlines

· • “ATF Special Agent Pleads Guilty to Drug Conspiracy” (FBI press release, May 6, 2010)

· • “Fulton County [GA] Deputy Sheriff Pleads Guilty to Corruption and Drug Offenses; Took Money to Protect Drug Dealers” (FBI press release, July 21, 2010)

· • “Former Lee County [SC] Sheriff Convicted of Racketeering and Drug Conspiracy” (FBI press release, November 11, 2010)

· • “Two Law Enforcement Officers Convicted for Participation in Drug Transaction” (FBI press release, December 9, 2010)

· • “Correction Officer Pleads Guilty to Drug Charges” (FBI press release, June 28, 2011)

· • “State Correction Officers Plead Guilty in Drug Trafficking Scheme” (FBI press release, May 12, 2010)

· • “Laredo [TX] Police Officer Sentenced to Lengthy Prison Term for Drug Trafficking” (FBI press release, April 11, 2011)

· • “Former Police Chief of Sullivan County [TX] Sentenced to Prison for Drug Trafficking” (FBI press release, April 21, 2011)

· • “Former Winn Parish [LA] Sheriff Convicted in Drug case” (Associated Press, February 25, 2011)

· • “Former St. Louis Metropolitan Police Department Sergeant Pleads Guilty to Federal Drug Charges” (FBI press release, April 23, 2012)

· • “Former Puerto Rico Police Officer Sentenced to 24 Years in Prison for Drug Trafficking Crimes” (FBI Press release, May 18, 2012)

   To seek out criminal activity in the most efficient manner possible, proactive law enforcement officers must conceal their identities and otherwise deceive the criminals they are stalking. As J. Wilson ( 1978 ) points out, both reactive and proactive law enforcement officers are exposed to opportunities for graft, but the latter are more severely tested: The reactive officer, “were he to accept money or favors to act other than as his duty required, would have to conceal or alter information about a crime already known to his organization” (59). The proactive agent, however, “can easily agree to overlook offenses known to him but to no one else or to participate in illegal transactions (buying or selling drugs) for his own rather than for the organization's advantage” (59). Undercover officers pretending to be criminals are difficult to supervise; the agency they work for often knows only what the agents tell it.

   There is also corruption in foreign countries that grow, process, or serve as transshipment stations for illegal substances. In fact, the corrupt official is an essential ingredient in the drug business, according to the President's Commission on Organized Crime ( 1986 ). The commission concluded that “[c]orruption linked to drug trafficking is a widespread phenomenon among political and military leaders, police and other authorities in virtually every country touched by the drug trade. The easily available and enormous amounts of money generated through drug transactions present a temptation too great for many in positions of authority to resist” (178). In addition to corruption, there is the problem of brutality. The militaries in many drug source and transshipment countries have earned widespread condemnation for violating basic human rights.

Two Hats

In 2010, the leader of a drug trafficking organization operating out of Ciudad Juárez, Mexico, was sentenced to twenty-seven years imprisonment in a U.S. federal court. The trafficker, Jesus Manuel Fierro-Mendez, was a Juárez police officer assigned to a special counternarcotics unit.

Source: Drug Enforcement Administration, press release, January 19, 2010.

Informants.   Corruption is often intertwined with the problem of informants. Informants come in two basic categories; the “good citizen” and the “criminal.” The former is such a rarity, particularly in drug law enforcement, that we will deal only with the criminal informant, the individual who helps law enforcement in order to further his or her own personal ends. These include vengeance, efforts to drive competition out of business, and/or financial rewards. Most often, however, the information is given to “work off a beef”—to secure leniency for his or her own criminal activities that have become known to the authorities. Cloyd ( 1982 ) found that one federal district had a specified menu for every “beef”: For each arrest resulting from informant assistance and yielding approximately the same amount of drugs that the defendant is being charged with, there is “a reduction of charges by one count. Being charged with two counts (one count of possession, one of possession with intent to sell), one arrest would get her a reduction of one count (felony possession) in exchange for an expedient plea of guilty. One good arrest and a guilty plea would reduce the charge to misdemeanor possession. Two good arrests would get her case dismissed” (188n).

   Obviously, the more involved in criminal activity the informer—“snitch” or confidential informant (CI)—is, the more useful is his or her assistance. While they are serving as informers, there is temptation to overlook his or her continued criminal activity. This raises serious ethical and policy questions. Should the informant be given immunity from lawful punishment in exchange for cooperation? If so, who is to make that determination? The agent who becomes aware of the informant's activities? The agent's supervisor? The prosecutor who is informed of the situation? A trial judge? Should a murderer be permitted to remain free because he or she is valuable to law enforcement efforts against drug trafficking? Should a drug addict—informant be allowed to continue his or her abuse in order to keep in touch with traffickers? If so, doesn't this contradict the goal of drug statutes, which is to curtail drug abuse? Should the government encourage informants even if they face serious physical danger (and they usually do)? Most drug agents would argue, however, that without informants there can be no effective drug law enforcement. The issues are complex and without definitive answers.

   There are other dangers. In South Florida, for example, given the number of law enforcement agencies and “given their heavy dependence on intelligence, it is inevitable that there are informants who inform on other informants, who are probably informing on them. A consequence of that is selective prosecution: arbitrary decisions made by police officers and agents as to who will go to jail and who will be allowed to remain on the street. Given the vast amounts of money at stake in the drug business, selective prosecution raises the specter of corruption” ( Eddy, Sabogal, and Walden 1988 , 85).

   Working closely with informants is potentially corrupting. The informant helps the agent to enter an underworld that is filled with danger—as well as great financial rewards. There is always concern that the law enforcement agent might become something else to the informer—a friend, an employee, an employer, or a partner. The rewards can be considerable: Agents can confiscate money and drugs from other traffickers or receive payment for not arresting traffickers; at the same time they can improve their work record by arresting competing dealers. It is often only a small step from using drug traffickers as informants to going into business with them.

Statutes and Legal Requirements

The legal foundation for federal drug law violations is Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as amended, usually referred to as the Controlled Substances Act (CSA). Among the provisions of the CSA is a set of criteria for placing a substance in one of five schedules ( Table 10.1 ). Following the federal model, most states have established the five-schedule system, but many “have chosen to reclassify particular substances within those five schedules. Variation also exists in the number of schedules employed by the states [North Carolina, for example, uses six] and in the purpose of these schedules” ( Illicit Drug Policies 2002 , 8). Massachusetts categorizes drugs on the basis of the penalty rather than using the federal scheme of potential for abuse and medical use. Like federal law, state statutes refer to the drug involved (e.g., cocaine or heroin), the action involved (e.g., simple possession, possession with the intent to sell, sale, distribution, or trafficking), and the number of prior offenses. Across states there is significant variation in the penalties for cocaine-, marijuana-, methamphetamine-, and Ecstasy-related offenses ( Illicit Drug Policies 2002 ).

   Drugs considered controlled substances under the CSA are divided into five schedules. A controlled substance is placed in its respective schedule based on whether it has a currently accepted medical use in treatment in the United States and its relative abuse potential and likelihood of causing dependence. Some examples of controlled substances in each schedule are outlined below. Drugs listed in Schedule I have no currently accepted medical use in treatment in the United States and, therefore, may not be prescribed, administered, or dispensed for medical use. In contrast, drugs listed in Schedules II to V have some accepted medical use and may be prescribed, administered, or dispensed for medical use.

TABLE 10.1 Schedule of Controlled Substances

SCHEDULE I

A. The drug or other substance has a high potential for abuse.

B. The drug or other substance has no currently accepted medical use in treatment in the United States.

C. There is a lack of accepted safety for use of the drug or other substance under medical supervision. Examples include heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”).

SCHEDULE II

A. The drug or other substance has a high potential for abuse.

B. The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.

C. Abuse of the drug or other substances may lead to severe psychological or physical dependence. · 1. Examples of single entity Schedule II narcotics include morphine and opium. Other Schedule II narcotic substances and their common name brand products include: hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®), and fentanyl (Sublimaze or Duragesic). · 2. Examples of Schedule II stimulants include: amphetamine (Dexedrine®, Adderall®), methamphetamine (Desoxyn®), and methylphenidate (Ritalin®). Other schedule II substances include: cocaine, amobarbital, glutethimide, and pentobarbital.

SCHEDULE III

A. The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II.

B. The drug or other substance has a currently accepted medical use in treatment in the United States.

C. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. ·    Examples of Schedule III narcotics include combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin) and products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with codeine). Also included are buprenorphine products (Suboxone® and Subutex®) used to treat opioid addiction. Examples of Schedule III non-narcotics include benzphetamine (Didrex), phendimetrazine, ketamine, and anabolic steroids such as oxandrolone (Oxandrin).

SCHEDULE IV

A. The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III. ·    An example of a Schedule IV narcotic is propoxyphene (Darvon® and Darvocet-N 100). Other Schedule IV substances include: alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium®), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).

B. The drug or other substance has a currently accepted medical use in treatment in the United States.

C. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III.

SCHEDULE V

A. The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule IV.

B. The drug or other substance has a currently accepted medical use in treatment in the United States.

C. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV. Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC and Phenergan with Codeine).

Source: Drug Enforcement Administration.

   People who are involved in the illegal drug business can be arrested and prosecuted for a number of different offenses: manufacture, importation, distribution, possession, or sale; conspiracy to manufacture, import, distribute, possess, or sell; or failure to pay the required income taxes on illegal income. Possession of drugs may be actual—for example, actually on the person, in pockets, or in a package that the person is holding; or constructive—not actually on the person but under his or her control, directly or through other people. Possession must be proven by a legal search, which usually requires a search warrant as per the Fourth Amendment (an important exception is at ports of entry). A search warrant requires the establishment of probable cause—providing a judge with sufficient evidence of a crime to justify a warrant. Drugs can easily be secreted in any variety of places, including inside the human body.

   The Comprehensive Crime Control Act of 1984 supplemented the CSA of 1970 by authorizing the doubling of a sentence for drug offenders with prior domestic or foreign felony drug convictions. The Anti-Drug Abuse Act of 1986 imposes mandatory prison sentences for certain drug offenses and a mandatory doubling of the minimum penalties for offenders with prior felony drug convictions. In 1988, the military's role in drug-law enforcement was substantially increased and Congress passed a statute to better control the diversion of precursor and essential chemicals for the manufacture of drugs. The Chemical Diversion and Trafficking Act, Subtitle A of the Anti-Drug Abuse Amendments of 1988, established record-keeping requirements and enforcement standards for more than two-dozen precursor and essential chemicals. State and federal statutes make the unauthorized trade in any of the listed substances equivalent to trafficking in the actual illegal drugs.

   The 1988 statute also created a complex and extensive body of civil penalties aimed at casual users. These include withdrawal of federal benefits, such as mortgage guarantees, and loss of a pilot's license or stockbroker's license at the discretion of a federal judge. Fines of up to $10,000 can be imposed for illegal possession of even small amounts of controlled substances. There are special penalties for the sale of drugs to minors. The statute permits imposition of capital punishment for murders committed as part of a continuing criminal enterprise or for the murder of a law enforcement officer during an arrest for a drug-related felony. The statute also established an Office of National Drug Policy headed by a director appointed by the president. The director is charged with coordinating federal drug supply reduction efforts, including international control, intelligence, interdiction, domestic law enforcement, treatment, education, and research.

   In response to the Ecstasy [MDMA] Anti-Proliferation Act of 2000, the U.S. Sentencing Commission raised the guideline for judges' sentences for trafficking MDMA. For 800 pills, about 200 grams, the sentence increased from fifteen months to five years; for 8,000 pills, the sentence increased from forty-one months to ten years. Enacted in 2003, the Illicit Drug Anti-Proliferation Act (sometimes known as the “Rave Act”) prohibits “knowingly opening, maintaining, managing, controlling, renting, leasing, making available for use, or profiting from any place for the purpose of manufacturing, distributing or using any controlled substance.” Penalties include imprisonment for up to twenty years, criminal fines of $500,000, and civil penalties of $250,000.

Conspiracy

Conspiracy is an agreement between two or more individuals to commit a criminal act; the agreement becomes the corpus (body) of the crime. Conspiracy requires proof (beyond a reasonable doubt) that two or more individuals planned to violate drug laws and that at least one overt act in furtherance of the conspiracy was made by a conspirator (e.g., the purchase of materials to aid in the transportation or dilution of illicit drugs). Conspiracy statutes are valuable tools for prosecuting drug offenders because:

· 1. Intervention can occur before the commission of a substantive offense.

· 2. A conspirator cannot shield himself or herself from prosecution because of a lack of knowledge of the details of the conspiracy or the identity of coconspirators and their contributions.

· 3. An act or declaration by one conspirator committed in furtherance of the conspiracy is admissible against each coconspirator (an exception to the hearsay rule).

· 4. Each conspirator is responsible for the substantive crimes of coconspirators; even late joiners can be held liable for prior acts of coconspirators if the latecomer's agreement is given with full knowledge of the conspiracy's objective.

Tax Laws

The Internal Revenue Code is organized into volumes covering a variety of taxes, in particular, U.S. income tax. The code requires residents and citizens (who may reside outside the country) to file a tax return that reveals the source and amount of all income from whatever source it is derived.

   In 1927, the U.S. Supreme Court decided the case of United States v. Sullivan (274 U.S. 259), which denied the claim of self-incrimination (Fifth Amendment) as an excuse for failure to file income tax on illegally gained earnings: It would be ridiculous if legitimate persons had to file income tax returns but criminals did not. This decision enabled the federal government to successfully prosecute Al Capone and members of his organization. Because persons in organized crime have obligations as taxpayers, they can be prosecuted for several acts:

· 1. Failing to make required returns or maintain required business records

· 2. Filing a false return or making a false statement about taxes

· 3. Willful failure to pay federal income tax or concealment of assets with intent to defraud

· 4. Helping others evade income taxes

Money Laundering

A U.S. Attorney General has pointed out that so much cash is involved in large, illicit drug-trafficking operations that tracking the money from these drug activities is often a more fruitful investigative endeavor than is tracking the underlying criminal activities ( Thornburgh 1989 ). Before passage of the Money Laundering Control Act of 1986, money laundering was not a federal crime, although the Department of Justice had used a variety of federal statutes to successfully prosecute money-laundering cases. The act consolidated these statutes with the goal of increasing prosecutions for this offense. Money laundering was made a separate federal offense punishable by a fine of $500,000 or twice the value of the property involved, whichever is greater, and twenty years imprisonment. The statute provides for the civil confiscation of any property related to a money-laundering scheme. Legislation enacted in 1988 allows the government to file a suit claiming ownership of all cash funneled through operations intended to disguise its illegal source. The courts can issue an order freezing all contested funds until the case is adjudicated.

Seizure and Forfeiture

Federal and state statutes provide for the forfeiture of property that is used in criminal activity or secured with the fruits of criminal activity. Forfeiture has proved particularly useful in dealing with drug traffickers. The Comprehensive Drug Abuse Prevention and Control Act of 1970 provides for the seizure of assets under certain conditions. This was extended through amendments in 1978 and 1984: The statute now permits forfeiture of all profits from drug trafficking and all assets purchased with such proceeds or traded in exchange for controlled substances. It authorizes the forfeiture of all real property used in any manner to facilitate violations of drug statutes, including entire tracts of land and all improvements regardless of what portion of the property facilitated the illegal activities. Currency, buildings, land, motor vehicles, and airplanes have all been confiscated ( Stahl 1992 ). The government also has the right to seize untainted assets as a substitute for tainted property disposed of or otherwise made unavailable for forfeiture ( Greenhouse 1994 ).

   A seizure can be made incident to an arrest or customs inspection or upon receipt of a seizure order. To obtain a seizure order (actually a warrant), the government must provide sworn testimony in an affidavit spelling out the property to be seized and why there is reason to believe that it is being used to commit crimes or was acquired with money from criminal activity—the same process used in securing a search warrant. The filing of criminal charges against the owner is not required. The owner of the property has a right to contest the seizure only after it has occurred: He or she must prove that the money or property was earned through legal enterprise. In 1993, the Supreme Court (United States v. Good Real Property, 510 U.S. 43) ruled that the government cannot seize real estate without providing the owner with a notice and opportunity to contest the proposed seizure. This decision applies only to real estate and not portable possessions. Vehicles and cash are the most frequently seized assets, because the pursuit of real property requires extensive financial investigation. “The investigative expense may be cost effective” however, if “the property is valuable and the potential for disrupting the criminal organization is high” ( Stellwagen 1985 , 5).

   There are two types of forfeiture proceedings: criminal and civil. Criminal forfeiture is applicable only as part of a successful criminal prosecution. “The defendant in the criminal case must be convicted of the crime involving the property, or the property cannot be subject to forfeiture” ( Poethig 1988 , 11). Thus, the government can use criminal forfeiture to seize the home of a convicted drug dealer who used the home to store drugs. Civil forfeiture, on the other hand, does not require criminal charges; civil forfeiture can proceed even in the absence of a criminal prosecution and has certain advantages over criminal forfeiture: The level of evidence required is considerably less than that in a criminal action, and the considerable due process guarantees accruing to a criminal defendant are not applicable in a civil action. Interestingly, civil forfeiture proceedings are brought against property that is involved in a criminal offense, not against a person. “Possession of the property in and of itself may not be illegal, but the property may be subject to seizure and forfeiture because of the way it was used. No criminal charge or conviction need exist against the owner of the property for the civil case to occur” ( Poethig 1988 , 11). Thus, the government can use civil forfeiture to seize an automobile that is used to transport drugs (facilitation forfeiture) even if no conviction resulted from this activity.

   In any number of jurisdictions, disputes have arisen over how to allocate the fruits of seized assets. Because these funds do not incur a political cost—not being linked to taxes—they are highly valued. However, “once the money reaches the local police, it often can become a political football with law enforcement and politicians squabbling over how to spend it” ( Soble 1991 , 23). In several California communities, for example, police officials wanted to put the money into drug law enforcement, but elected officials insisted instead on increasing the uniformed police force. There is also concern that pressure to produce revenue will encourage legally questionable activity and even alter the basic goal of drug law enforcement.

   Forfeiture statutes of some states permit all seized assets to be returned to the initiating agency; others provide for distribution to all law enforcement agencies involved and the prosecutor's office; still others permit no proceeds to be returned to law enforcement and, instead, require that they be placed in an education fund. Law enforcement agencies in these states are able to bypass the requirement by having the case “adopted” by a federal agency such as the DEA or FBI, which then passes it off to the U.S. Attorney. The adoption procedure can result in up to 80 percent of the proceeds being returned to the initiating department ( Worrall 2008 ). Increased police assets via forfeiture provide an incentive for local governments to reduce their allocations for policing ( Skolnick 2008 ). Forfeiture laws engender considerable controversy because of sharing provisions.

   Intertwined with this concern is that expressed over the seizure of property owned by innocent third parties. Three fraternity houses that were seized at the University of Virginia in 1991, for example, were owned by alumni, not the current occupants, some of whom were arrested for drug violations. (Two houses were returned before the 1991–1992 school year began.) Innocent parties can be deprived of a residence, vehicle, business, or cash until they are able to prove they were not involved in law-violating activity—a reversal of the normal presumption of innocence. To get back seized property, the owner needs an attorney, and litigation can take several months without any guarantee of success. For people who make the “mistake” of traveling with large amounts of cash—particularly if they are black, Hispanic, or Asian—the results can be more than an inconvenience. A study by the Pittsburgh Press revealed several cases in which the cash of innocent people was seized at airports and kept for years without any criminal charges being filed ( Schneider and Flaherty 1991 ). “Overcoming the burden of proof can be hard even for the most upright citizens. How does a mother prove she didn't know her son was using the family car to transport drugs? How does a landlord prove he didn't know a tenant was a drug dealer? … The effort is also expensive, and even if you win, you're still out the money to pay your lawyer, which can be more than the value of the property you've recovered” ( Chapman 1992 , 23). In 1996, the Supreme Court determined that property can be seized even when the owner was innocent of any wrongdoing. In this case, Bennis v. Michigan (517 U.S. 1163), a jointly owned car was impounded after the husband used it to solicit a prostitute. In response to these criticisms, in 2000 the 1984 statute was revised to require the government to prove that confiscated property either had been used for illegal activity or was purchased with the proceeds of criminal activity. In 1989, the Supreme Court, in a five-to-four decision, ruled that the government, under the Comprehensive Forfeiture Act, can freeze the assets of criminal defendants before trial (Caplin and Drysdale v. United States, 491 U.S. 616; United States v. Monsanto, 491 U.S. 600).

   Forfeiture has also been criticized as a plea-bargaining device for drug kingpins. They negotiate lighter sentences by promising to reveal hidden assets and not put up court challenges to their seizure. Law enforcement agencies, eager for additional funds, promote leniency for those at the top of the drug-trafficking ladder while those down below, without substantial hidden assets, face significant penalties ( Navarro 1996 ). There is criticism that forfeiture can distort the purpose of drug law enforcement, for example, police delaying raids until drug caches are depleted and cash maximized (Worrall and Kovandzic 2008). Or it can result in a “get out of jail free” card, a plea-bargaining device for drug kingpins. They negotiate lighter sentences by promising to reveal hidden assets and not put up court challenges to their seizure.

Drug Law Enforcement Agencies

As was noted earlier, local efforts against drug trafficking are usually directed at midlevel dealers, although most frequently, it is the low-level street dealer who is arrested and prosecuted at the local level. Federal drug law enforcement seeks to disrupt illicit trafficking organizations and to reduce the availability of drugs for illicit use.

Levels of Drug Law Enforcement

There are five levels of drug law enforcement ( Kleiman 1985 ):

· 1. Source control: This comprises actions aimed at limiting cultivation and production of poppies and opium, coca and cocaine, and marijuana. Both the State Department and the Drug Enforcement Administration have agents assigned to foreign countries.

· 2. Interdiction: The interception of drugs being smuggled into the United States is primarily the role of the Coast Guard and Customs and Border Protection.

· 3. Domestic distribution: The disruption of high-level trafficking is usually the responsibility of the Drug Enforcement Administration and the Federal Bureau of Investigation.

· 4. Wholesaling: The focus on midlevel dealing is usually the role of state and local law enforcement.

· 5. Street sales: Low-level dealing, often by addicts supporting their own drug habits, is usually left to local law enforcement.

   On the federal level, because the United States, unlike most other democratic nations, does not have a national police force, the job of carrying out these objectives falls on a confusing number of agencies in several departments—Justice, Treasury, Homeland Security, Defense—whose responsibilities for enforcing drug laws often overlap. This fragmentation is the result of the ad hoc creation of law enforcement agencies at the national level; each time a particular problem arose, an agency was established without significant attention to the problem of coordination. We will discuss the agencies in the order listed in  Table 10.2 .

Drug Enforcement Administration (DEA)

The mission of the Drug Enforcement Administration is to enforce the controlled substances laws and regulations of the United States and bring to justice those organizations and principal members of organizations involved in the illegal growing, manufacture, or distribution of controlled substances in or destined for the United States. The DEA recommends and supports nonenforcement programs aimed at reducing the availability of illicit controlled substances on the domestic and international markets. The agency manages a national drug intelligence network in cooperation with federal, state, local, and foreign officials to collect, analyze, and disseminate strategic, investigative, and tactical intelligence information to U.S. law enforcement and intelligence agencies, and, when appropriate, to foreign counterparts.

TABLE 10.2 Federal Drug Law Enforcement Agencies

DEPARTMENT OF JUSTICE

Drug Enforcement Administration

Federal Bureau of Investigation

Bureau of Alcohol, Tobacco, Firearms and Explosives

U.S. Marshals Service

DEPARTMENT OF HOMELAND SECURITY

Immigration and Customs Enforcement

Customs and Border Protection

Secret Service

Coast Guard

DEPARTMENT OF THE TREASURY

Internal Revenue Service

POSTAL SERVICE

Postal Inspection Service

DEPARTMENT OF AGRICULTURE

U.S. Forest Service

DEPARTMENT OF THE INTERIOR

Bureau of Land Management

National Park Service

   The DEA evolved out of several predecessor agencies, particularly the Federal Bureau of Narcotics (see  Chapter 8 ). It is a single-mission agency responsible for enforcing federal statutes dealing with controlled substances by investigating alleged or suspected major drug traffickers. The DEA is also responsible for regulating the legal trade in such controlled substances as morphine, methadone, oxycodone, and barbiturates. Diversion agents conduct accountability investigations of drug wholesalers, suppliers, and manufacturers. They inspect the records and facilities of major drug manufacturers and distributors, and special agents investigate instances in which drugs have been illegally diverted from legitimate sources.

   Headquartered in Arlington, Virginia, the DEA has 227 domestic offices in twentyone field divisions throughout the United States and eighty-seven foreign offices in sixty-three countries. Of the DEA's approximately 11,000 permanent positions, more than 90 percent are located in DEA headquarters and domestic field divisions. The remaining positions are stationed in DEA foreign offices. DEA special agents are stationed in dozens of countries where their mission is to gain cooperation in international efforts against drug trafficking and to help train foreign enforcement officials.

   The DEA has five military-trained squads called Foreign-deployed Advisory Support Teams (FAST) of ten agents each that, since 2005, have been deployed to fight drug trafficking organizations in countries as far flung as Honduras and Afghanistan, blurring the lines between the “war on drugs” and the “war on terrorism.” Working with specially vetted local law enforcement officers, FAST usually operates with a low profile to avoid the potential of a nationalist backlash ( Savage 2011 ).

   In Honduras, in addition to FAST squads, U.S. special forces and helicopter pilots are deployed in remote base camps to help local forces stem the flow of drugs heading north from Colombia ( Shanker 2012 ). In 2012, residents of the Mosquito Coast of Honduras on the Carribean Sea, an area used to move cocaine from Colombia and Venezuela to Mexico, rioted over accusations that DEA agents killed innocent civilians, which the DEA denies ( Cave 2012b ).

The DEA and Its Antecedent Agencies

1973–Present: Drug Enforcement Administration

1968–1973: Bureau of Narcotics and Dangerous Drugs

1930–1968: Federal Bureau of Narcotics

1927–1930: Bureau of Prohibition

1915–1927: Bureau of Internal Revenue

   The basic approach to DEA drug law enforcement is the buy and bust or the controlled buy. Typically, a drug agent is introduced to a seller by an informant. The agent arranges to buy a relatively small amount of drugs and then attempts to move farther up the organizational ladder by increasing the amount purchased. When arrests are made, DEA agents attempt to “flip” the suspect, convincing him or her to become an informant, particularly if the person has knowledge of the entire operation, so that a conspiracy case is affected. As was discussed above, the use of informants is problematic.

Federal Bureau of Investigation (FBI)

The FBI is as close to a federal police force as exists in the United States. Its broad investigative mandate was expanded in 1982, when the FBI was given concurrent jurisdiction with the DEA for drug law enforcement and investigation. In addition, the administrator of the DEA is now required to report to the director of the FBI, who has overall responsibility for supervising drug law enforcement efforts and policies. Despite this increased mandate, the primary role of the FBI is to deal with domestic espionage and terrorism.

Customs and Border Protection (CBP)

Customs and Border Protection (CBP) personnel regulate the movement of carriers, persons, and commodities between the United States and other nations. It is the largest uniformed federal law enforcement agency. CBP has authority to search outbound and inbound shipments. Its more than 21,000 officers screen passengers (more than 300 million persons annually) and cargo at 330 points of entry into United States. CBP Border Patrol Agents are assigned to U.S. borders with Canada and Mexico to prevent illegal entry of persons, and contraband. CBP is at the forefront of efforts against human and counterfeit product trafficking, working with commercial carriers, often signing cooperative agreements, to enhance the carriers' ability to prevent their equipment from being used to smuggle drugs and other contraband. CBP's Office of Air and Marine is the world's largest aviation and maritime law enforcement organization. The agency collects over $30 billion annually in tariffs, and CBP agricultural specialists are responsible for preventing the entry of harmful pests, and plant and animal diseases that may threaten U.S. agriculture and the food supply.

   BCP is not bound by Fourth Amendment protections that typically restrain domestic law enforcement. Agents do not need probable cause or warrants to engage in search and seizure at ports of entry; certain degrees of suspicion will suffice. The typical case is a “cold border bust,” the result of an entry checkpoint search. Because it is impractical if not impossible to thoroughly search most vehicles and individuals entering the United States, agents have developed certain techniques for minimizing inconvenience to legitimate travelers and shippers while targeting those most likely to be involved in smuggling. Besides being alert to various cues that act as tip-offs, the officials at border-crossing points have computers containing information such as license plate numbers and names of known or suspected smugglers. People arrested become targets for offers of plea bargaining in efforts to gain their cooperation in follow-up enforcement efforts.

   BCP is hampered by the need to patrol more than 12,000 miles of international boundary. The frontiers of the United States, to the north and the south, “are the longest undisputed, undefended borders on earth” ( F. Weiner 2002 , 14). About half the drugs entering the United States come through commercial ports aboard container ships, where the drugs are secreted in tightly sealed steel intermodal freight containers, millions of which enter the country every year. Officials can inspect only a small number (about 10 percent) of these containers, and without advance information, the drugs typically pass right through the ports. Drugs that are intercepted are easily replaced.

   CBP has been plagued by charges of corruption on the U.S.-Mexico border. In part, the result of dramatic increases in the number of agents and tougher enforcement that has driven smugglers to engage in greater efforts at compromising security. There is concern that smugglers are sending operatives to take jobs in border enforcement (Archibald and Becker 2008). In 2011, a CBP inspector pled guilty to being a member of a drug trafficking organization and facilitating the smuggling of drugs and aliens into the United States; he received a seventeen-year sentence (FBI press release, July 6, 2011).

Immigration and Customs Enforcement (ICE)

Immigration and Customs Enforcement (ICE) is charged with the investigation and enforcement of over 400 federal statutes within the United States, and maintains attachés at major U.S. embassies overseas. ICE has more than 20,000 employees assigned to offices in all fifty states and forty-seven foreign countries; more than 7,000 are special agents responsible for investigating a wide range of domestic and international activities arising from the illegal movement of people and goods into and out of the United States. ICE investigates immigration crime, human, drug, and weapons smuggling, financial crimes, export matters, and cyber crime.

   The Cyber Crimes Section (CCS) is responsible for developing and coordinating investigations of immigration and customs violations where the Internet is used to facilitate the criminal act. CCS investigative responsibilities include fraud, theft of intellectual property rights, money laundering, identity and benefit fraud, the sale and distribution of controlled substances, illegal arms trafficking, and the illegal export of strategic/controlled commodities, and the smuggling and sale of other prohibited items such as art and cultural property.

   In 2009, the Drug Enforcement Administration and ICE entered into an interagency agreement to increase the number of agents targeting international drug traffickers, improve and enhance information and intelligence sharing, and promote effective coordination between the agencies. According to the agreement, an unlimited number of ICE agents for will be cross-designated to investigate violations of the Controlled Substances Act at border crossings in coordination with DEA. In addition, ICE now will be able to investigate these violations overseas while coordinating with the DEA (DEA press release, June 19, 2009).

Coast Guard

The Coast Guard, formerly part of the U.S. Department of Transportation and now part of the U.S. Department of Homeland Security, is responsible for drug interdiction at sea. Coast Guard personnel do not have to establish probable cause before boarding a vessel at sea. Coast Guard responsibilities include maritime safety and security on, under and over the high seas and waters subject to the jurisdiction of the United States. Coast Guard personnel are federal law enforcement officers who are often stationed aboard naval vessels on drug interdiction patrol.

   “Responsible in large part for U.S. drug interdiction efforts, the Coast Guard's strategy has been mainly directed toward intercepting mother ships as they transit the major passes of the Caribbean. To effect this ‘choke point’ strategy, the Coast Guard conducts both continuous surface patrols and frequent surveillance flights over waters of interest, and boards and inspects vessels at sea” ( President's Commission on Organized Crime 1986 , 313). In 2008, for example, a Coast Guard law enforcement detachment boarded a Panamanian flagged vessel on the Caribbean and seized 1,930 kilograms of cocaine; they also arrested the ten crew members (DEA press release, October 2, 2008).

   Smugglers bringing drugs from Colombia across the Caribbean to the Florida coast carry extra fuel for the 700-mile round trip in boats that are thirty to forty-five feet long, capable of carrying 3,000 pounds of cocaine, and travel at nearly seventy miles per hour. In response, the Coast Guard modernized a tactic that had last been employed during the Prohibition Era using fixed wing aircraft: Helicopter-borne sharpshooters disable the engines of speedboats that refuse to follow orders of Coast Guard vessels. In response, drug traffickers are employing self-propelled semi-submersible and submersible vessels designed to evade detection and are easily scuttled when intercepted for the purpose of destroying the contraband and avoiding prosecution.

Internal Revenue Service

The mission of the Internal Revenue Service (IRS), an agency of the Treasury Department, is to encourage and achieve the highest possible degree of voluntary compliance with tax laws and regulations. When such compliance is not forthcoming or not feasible, as in the case of persons involved in drug trafficking, the Criminal Investigation (CI) division receives the case. Agents examine bank records, canceled checks, brokerage accounts, property transactions, and purchases, compiling a financial biography of the subject's lifestyle in order to prove that proper taxes have not been paid according to the net worth theory.

   Drug entrepreneurs have devised ways to successfully evade taxes by, for example, dealing in cash, keeping minimal records, and setting up fronts. This is countered by the indirect method known as the net worth theory: “The government establishes a taxpayer's net worth at the commencement of the taxing period [which requires substantial accuracy], deducts that from his or her net worth at the end of the period, and proves that the net gain in net worth exceeds the income reported by the taxpayer” ( E. Johnson 1963 , 17–18). In effect, the IRS reconstructs the total expenditures of the taxpayer by examining his or her standard of living and comparing it with reported income. The government can then maintain that the taxpayer did not report his or her entire income; the government does not have to show a probable source of the excess unreported gain in net worth.

   The IRS employs about 2,800 special agents in the Criminal Investigation division. While the primary role of the IRS is the collection of revenue and compliance with federal statutory tax codes, including the Internal Revenue Code, CI seeks evidence of criminal violations for prosecution by the Department of Justice. In particular, agents seek out information relative to income that has not been reported: “Additional income for criminal purposes is established by both direct and indirect methods. The direct method consists of the identification of specific items of unreported taxable receipts, overstated costs and expenses (such as personal expenses charged to business, diversion of corporate income to office-stockholders, allocation of income or expense to incorrect year in order to lower tax, etc.), and improper claims for credit or exemption” (Committee on the Office of Attorney General 1974, 49–50).

   Financial investigations are by their nature very document intensive. They involve records, such as bank account information and real estate files, which point to the movement of money. Any record that pertains to, or shows the paper trail of events involving money is important. The major goal in a financial investigation is to identify and document the movement of money during the course of a crime. The link between where the money comes from, who gets it, when it is received and where it is stored or deposited, can provide proof of criminal activity.

   As a result of the excesses revealed in the wake of the Watergate scandal during the presidency of Richard Nixon, Congress enacted the Tax Reform Act of 1976. The act reduced the law enforcement role of the IRS and made it quite difficult for law enforcement agencies other than the IRS to gain access to income tax returns. Amendments in 1982 reduced the requirements and permit the IRS to better cooperate with the efforts of other federal agencies investigating organized crime, particularly drug traffickers.

   In addition to investigating criminal violations of the Internal Revenue Code, IRS jurisdiction includes the Bank Secrecy Act and money laundering statutes. Only the IRS can investigate criminal violations of the IRS code. Due to increased use of automation for financial records, CI special agents are trained to recover computer evidence and use specialized forensic technology to recover financial data that may have been encrypted.

U.S. Marshals Service

The Marshals Service is the oldest federal law enforcement agency, dating back to 1789. During the period of westward expansion, the U.S. marshal played a significant role in the “Wild West,” where he was often the only symbol of law and order. In the past, marshals have also been used in civil disturbances as an alternative to military intervention. Today, they provide security for federal court facilities and the safety of federal judges; transport federal prisoners; apprehend fugitives; serve civil writs issued by federal courts, which can include the seizure of property and provide for the custody, management, and disposal of forfeited assets. Their most important task relative to drug trafficking is responsibility for administering the Witness Security Program, authorized by the Organized Crime Control Act of 1970.

   The Marshals Service provides 24/7 security to witnesses while they are in a highthreat environment, including pretrial conferences, trial testimonials, and other court appearances. Witnesses and their families typically get new identities with authentic documentation and financial assistance for housing, subsistence for basic living expenses, and medical care. Job training and employment assistance may also be provided.

   Some critics of the program have charged that the Marshals Service shields criminals not only from would-be assassins but also from debts and lawsuits. In an attempt to remedy this, an amendment to the 1984 Comprehensive Crime Control Act directs the Justice Department to stop hiding witnesses who are sued for civil damages and to drop from the program participants linked to new crimes. But the program still provides career criminals with “clean” backgrounds they can use to prey on or endanger an unsuspecting public.

Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)

The Bureau of Alcohol, Tobacco, Firearms and Explosives dates back to 1791, when a tax was placed on alcoholic spirits. It eventually evolved into the Prohibition Bureau, which, with the repeal of Prohibition, became known as the Alcohol Tax Unit. The bureau was given jurisdiction over federal firearms statutes in 1942 and over arson and explosives in 1970. ATF agents often encounter drug traffickers during their investigation of firearms and explosives violations. They have been particularly active in efforts against outlaw motorcycle clubs, which often traffic in firearms and drugs.

Bureau of Land Management & National Park Service-Department of the Interior

The Bureau of Land Management (BLM) administers public lands totaling approximately 253 million acres. BLM uniformed law enforcement rangers and plainclothes special agents are located in each of the western states that have BLM lands. They work to identify, investigate, disrupt, and dismantle marijuana cultivation, methamphetamine production, and drug smuggling activities on BLM lands. The National Park Service manages all national parks, many national monuments, and other conservation and historical properties. The agency employs uniformed law enforcement rangers to patrol roads and conduct surveillance of trails and backcountry areas to counter drug smuggling, marijuana cultivation, and methamphetamine production.

U.S. Forest Service-Department of Agriculture

The U.S. Forest Service (FS) manages 193 million acres in forty-four states, the Virgin Islands, and Puerto Rico encompassing 155 national forests and twenty national grasslands. Most of this land is located in extremely rural areas of the United States. In support of this mission, the FS employs uniformed law enforcement officers and plain-clothes special agents. They target drug trafficking organizations known to be active in sixteen states and operating on sixty-three national forests. Three drug enforcement issues are of specific concern to the FS: marijuana cultivation, methamphetamine production, and smuggling across international borders.

Postal Inspection Service

The Postal Inspection Service, among its several responsibilities, investigates the use of the U.S. mail to transport drugs.

Department of Defense (DOD)

In 1878, congressional Democrats enacted the Posse Comitatus (literally “force of the county”) Act to stop Republican presidents from using the army to further Reconstruction in the states of the erstwhile Confederacy. The act (as amended) makes it a crime to use the military as a domestic police force. Until 1981, DOD limited its involvement in drug law enforcement to lending equipment and training civilian enforcement personnel in the use of military equipment. In that year, as part of a new “War on Drugs,” Congress amended the Posse Comitatus Act authorizing a greater level of military involvement in civilian drug law enforcement, particularly the tracking of suspect ships and planes and the use of military pilots and naval ships to transport civilian enforcement personnel. As a result of this legislation, DOD provides surveillance and support services, using aircraft to search for smugglers and Navy ships to tow or escort vessels seized by the Coast Guard to the nearest U.S. port. The legislation authorized the military services to share information collected during routine military operations with law enforcement officials and to make facilities and equipment available to law enforcement officials. Further amendments led to the use of military equipment and personnel in efforts against cocaine traffickers in Bolivia, Colombia, and Peru.

U.S. Navy on Drug Patrol

When the Customs and Border Protection plane spotted two forty-foot boats with twin engines off the coast of Panama, the pilot radioed a U.S. Navy frigate stationed nearby. A helicopter launched from the frigate gave chase and the people in the boats discarded their cargo and made a run for it; they escaped and sailors recovered nearly 5,000 pounds of cocaine.

   A few months later, a U.S. Navy frigate operating in waters off Colombia's west coast with a Coast Guard contingent aboard recovered almost 5,000 pounds of cocaine that had been jettisoned by an escaping “go-fast” vessel.

Source: Shauhnessy 2012 ;  Wiltrout 2012 .

   The 1981 statute and subsequent amendments maintain the prohibition against the involvement of U.S. military personnel in arrest and seizure activities. This prohibition was based on the fear that further DOD involvement in drug law enforcement could:

· ▸ Compromise U.S. security by exposing military personnel to the potentially corrupting environment of drug trafficking (Sciolino and Engelberg 1988)

· ▸ Impair the strategic role of the military

· ▸ Present a threat to civil liberties

   Furthermore, U.S. military officials have traditionally opposed involvement of the armed forces in law enforcement. In 1988, however, legislation was overwhelmingly approved to dramatically expand the role of the military and allow the arrest of civilians under certain circumstances.

   The U.S. Department of State uses former military pilots to fly helicopter gunships, transport planes, and crop dusters used by U.S. and foreign drug agents in countries where U.S. military operations are barred. Early in 1990 and again in 2006, National Guardsmen were deployed to search for drugs and illegal immigrants along the border with Mexico and at ports of entry. (As members of state militias, the National Guard can perform in this capacity because they are not governed by the Posse Comitatus Act.)

INTERPOL

The International Police Organization, known by its telegraphic designation INTERPOL, assists law enforcement agencies with investigative activities that transcend international boundaries.

   As of 2009, there were 187 INTERPOL member countries; a country becomes a member merely by announcing its intention to join. In each member country there is a National Central Bureau (NCB) that acts as a point of contact and coordination with the General Secretariat, which is headquartered in Lyon, France. The General Secretariat has a staff of around 500 people, some of whom are law enforcement officers, from more than eighty different countries. INTERPOL is under the day-to-day direction of a secretary general; it is a coordinating body and has no investigators or law enforcement agents of its own.

   The United States National Central Bureau (USNCB) is the entity through which the United States functions as an INTERPOL member and serves as a point of contact for U.S. federal, state, local, and tribal law enforcement for the international exchange of information. Responsibility for the management of the USNCB is shared by the Department of Justice and the Department of Homeland Security. Senior management positions in the USNCB rotate between the two departments every three years.

   NCBs can instantly communicate with other NCBs and the INTERPOL General Secretariat, and INTERPOL member countries can instantly access a wide range of criminal information located in INTERPOL's databases, including drug- and terrorism-related information. This information comes from queries, messages, intelligence, and submissions from law enforcement officials in member countries ( U.S. Department of Justice 2009 ).

   The USNCB receives about 12,000 requests for assistance from federal, state, and local law enforcement agencies each year. These are checked and coded by technical staff and entered into the INTERPOL Case Tracking System (ICTS), a computer-controlled index of people, organizations, and other crime information items. The ICTS conducts automatic searches of new entries, retrieving those that correlate with international crime. The requests are forwarded to senior staff members, who serve as INTERPOL case investigators. These are usually veteran agents from a federal agency whose experience includes work with foreign police forces. Each investigator is on loan from his or her principal agency.

   Requests for investigative assistance include a whole range of criminal activity—murder, drug violations, illicit firearms traffic—and often involve locating fugitives for arrest and extradition. The bureau also receives investigative requests for criminal histories, license checks, and other ID verifications ( Fooner 1985 ). The Financial and Economic Crime Unit at INTERPOL headquarters facilitates the exchange of information about offshore banking and money-laundering schemes. Monitoring this type of activity can sometimes lead to identifying suspects involved in drug trafficking who had previously escaped detection.

Street-Level Law Enforcement

Efficient street-level enforcement, argues Moore ( 1977 ), is a strategy worth pursuing, even if there is displacement—sellers moving to new locations and becoming more cautious. Caulkins ( 1992 ) agrees that even when there is complete displacement, benefits to society accrue. Because street-level enforcement makes sellers more cautious and therefore more difficult to find, the buyer is forced to spend more time searching for a connection and less time searching for money (criminal opportunity) or actually using drugs. Under such conditions many users might be motivated to seek treatment, although there is often a shortage of available treatment programs. New users in particular will have difficulty “scoring.” If this situation becomes widespread, profits from drug wholesaling will drop as if there were a drop in consumer demand.

   Mazerolle, Sachs, and Rombout ( 2007 ) classify street-level enforcement into three generic categories:

· 1. Community-wide policing approaches involve a wide array of diverse interventions that rely on the police forging partnerships (e.g., with other police agencies, community entities, regulators, city inspectors), and implementing strategies that are targeted at relatively large areas such as across entire communities or neighborhoods to address drug markets.

   This category involves partnerships with local councils, community groups, regulators, inspectors, business groups, and other crime-control agencies such as probation and parole departments. It uses such tactics as knock-and-talks, drug patrols, local police storefronts, drug hot lines, foot and bike patrols, neighborhood revitalization, block watch, neighborhood watch, and arrest referral to drug treatment.

· 2. Geographically focused policing approaches typically involve the use of problemsolving models and/or partnerships with third parties, such as regulators, service providers, government agencies.

   This category uses problem-oriented policing—partnering with nonpolice agencies in response to identified community problems such as abandoned vehicles and buildings—cooperative efforts with regulatory agencies using civil remedies—and crime control through environmental design: surveillance cameras, additional street lighting, limiting access to problem areas by reconfiguring traffic patterns.

· 3. Hot-spots policing uses traditional approaches to drug law enforcement that are unfocused and rely principally on law enforcement resources such as directed patrols and crackdowns, police-only activities that are geographically focused on drug hot spots.

   This category uses crackdowns—abrupt escalations in law enforcement activities intended to increase the perceived or actual threat of apprehension—undercover “buy and bust” operations, and intensive/saturation patrol. “[I]t is unlikely that buy-bust operations aimed specifically at street dealers will significantly disrupt the distribution system. Sellers operating at this level are easily replaced and while buybust operations may result in large number of arrests, convictions rarely lead to lengthy sentences” (Hough 2005, 25).

   In Lynn, Massachusetts, a drug task force made up of six state police officers and a city detective was deployed to decrease the flagrant selling of heroin in the city's High Rock area. Open drug dealing poses special threats. “Some neighborhood residents, particularly children, may become users; and … the behavior of buyers and sellers will be disruptive or worse. In poor neighborhoods, the opportunity for quick money offered by the illicit market may compete with entry-level licit jobs and divert labor-market entrants from legitimate careers. When the drug sold is heroin, residents are likely to be bothered by users ‘nodding’ in doorways and heroin-using prostitutes soliciting” ( Kleiman 1988 , 10). The goal was achieved, and drugs were harder to purchase in the area. This led to an increase in the number of people seeking treatment for drug abuse. A significant reduction in street crime was also reported for the area ( Kleiman 1988 ). The drying up of immediate sources of heroin can potentially reduce experimentation, although long-term users will merely be inconvenienced. The time and energy required to establish new sources, however, might otherwise be spent on drug use and criminality. If treatment is available, the crackdown might serve as an incentive for entering a treatment program.

   In New York City, a 1984 street-level enforcement effort known as Operation Pressure Point (OPP) was designed to improve the quality of life and reduce drug-related crime in an area of the city's Lower East Side. Drug trafficking in the area had become so blatant that residents and their political representatives demanded police action. OPP instituted aggressive patrolling by uniformed officers, cleared abandoned buildings and parks of drug users, and sent out detectives to make “buy-and-bust” arrests. The risk of arrest increased dramatically for both buyers and sellers, and most of them abandoned the area and others resorted to low-profile trafficking. OPP followed up these activities with programs designed to strengthen the community and increase cooperation with and support for the police. The program achieved its goals and neighborhood residents reported being very satisfied. Similar operations in other parts of New York City, however, have not been as successful ( Zimmer 1990 ). Hough (2005) cautions that this type of drug enforcement can have the unintended consequence of increased revenue for remaining dealers, who face less competition.

Drug Market Intervention Initiative.   A relatively new approach to the problem of street-level drug markets is the brainchild of David Kennedy of New York City's John Jay College of Criminal Justice. Instead of the traditional “hot spot” approach, after a particular drug market is identified, violent dealers are arrested while nonviolent ones are brought to a “call-in” where they face a roomful of law enforcement officers, social service providers, community figures, ex-offenders, and their own parents, relatives, and neighbors: “The drug dealers are told that (1) they are valuable to the community, and (2) the dealing must stop. They are offered social services. They are informed that local law enforcement has worked up cases against them, but that these cases will be ‘banked’ (temporarily suspended). Then they are given an ultimatum: ‘If you continue to deal, the banked cases against you will be activated’” ( Kennedy 2009 , 13).

   The “call-in” provides a forum at which everyone affected can say to the dealers: “Enough!” Dealers are told by relatives that while they are loved, their behavior is unacceptable. This is backed by law enforcement officers who explain: “We want to take a chance on you. We have done the investigation, and we have cases against you ready to go. You could be in jail today, but we do not want to ruin your life. We have listened to the community. We do not want to lock you up, but we are not asking. This is not a negotiation. If you start dealing again, we will sign the warrant, and you will go to jail.”

   Preliminary research into this approach, which is being used in more than 25 cities, has revealed a remarkable level of success in shutting down drug markets. Referred to as a “ceasefire,” Kennedy's approach is also used to reduce gang violence ( Seabrook 2009 ).

Drug-Sniffing Dogs

In 2000, the Supreme Court ruled (Indianapolis v. Edmond et al. 531 U.S. 32) that in the absence of any suspicion, police checkpoints that briefly detain drivers and use drug-sniffing dogs violate the Fourth Amendment. Checkpoints are permitted, however, for discovering and taking intoxicated drivers off the road because that protects public safety. In 2005, however, the Court ruled (Illinois v. Caballes, 543 U.S. 405) that during a routine traffic stop police may use a trained dog to sniff the car for drugs. Such drug-sniffing activity had already been ruled permissible for luggage at airports.

   Street-level enforcement is expensive and, if it is to be more than briefly effective, must be combined with sufficient prison space to accommodate the increase in population. In an attempt to stem the 1985 crack epidemic in New York City, police initiated a street-level crackdown with impressive results: Crack arrests and jailings reached record levels; felony drug arrests went up 21 percent the first year and 70 percent the next. Total jail sentences for drug felonies increased by 60 percent in 1987. Nevertheless, the street price of crack dropped steadily. And in response to the stepped-up police activity, crack dealers began recruiting thousands of young addicts to make street sales, overwhelming a number of city neighborhoods as well as the city's overextended police force. Placing unusually large resources in one area also raises the possibility that the problem will be displaced into areas where law enforcement efforts are less concentrated. Furthermore, the reduction of crime in Lynn, Massachusetts, discussed earlier was short-lived, and a similar crackdown in Lawrence, Massachusetts, actually resulted in an increase in crime, particularly burglary and robbery ( A. Barnett 1988 ;  Bouza 1990 ).

   In New York, in response to intensive police efforts against street dealing, sellers moved away from high-profile and vulnerable street sales to mobile delivery services using pagers and/or cellular telephones. As a result of the extra costs associated with this type of drug trafficking, in terms of both the equipment and time spent making deliveries, sellers began dealing only with those who could purchase large amounts at once, with the attendant risk of increased consumption. These buyers may become dealers to their friends. This strategy can also move drug selling from urban areas into the suburbs, making drugs more accessible to those who were reluctant to purchase in neighborhoods with which they are not familiar.

   Street-level enforcement efforts bring with them the specter of corruption and related abuses: “Bribery, perjured testimony, faked evidence and abused rights in the past have accompanied street-level narcotics enforcement. Indeed, it was partly to avoid such abuses that many police departments began concentrating on higher-level traffickers and restricted drug efforts to special units” ( Moore and Kleiman 1989 , 8). These special units have brought problems of their own. New York provides an example. In 1971, to centralize drugs, vice, and organized crime enforcement and to prevent corruption through stricter supervision, the city established the Organized Crime Bureau. Early in 1992, the police department's chief of inspectional services submitted a confidential report citing recent cases in which the bureau's narcotic officers were accused of lying to strengthen cases and to obtain search warrants; there were no accusations of corruption. The report noted: “Of all units in the department, the greatest integrity hazards and vulnerability exist in narcotics” ( Raab 1992 ).

Issues in Drug Law Enforcement

In addition to those discussed at the beginning of this chapter, several perplexing issues complicate drug law enforcement. The first involves measuring success: How can we determine whether drug law enforcement in general or specific activities in particular are successful? What criteria can provide a standard for measuring success? The number of people arrested, convicted, or imprisoned? The amount of drugs seized? The level of purity or price of the product sold on the streets? The number of people admitted to hospital emergency rooms for drug overdoses? The number of people seeking admission to drug treatment programs? In practice, we use all of these, with often confusing results. For example, increased arrests and drug seizures have often been accompanied by declining prices and greater levels of purity. A 1983 report by the U.S. Comptroller General points out that while enhanced federal resources increased the amount of illegal drugs seized, purity at the retail level increased while prices fell. The Comptroller General also revealed that some drug seizures are counted several times by different agencies that are eager to claim credit and improve their statistics. Sometimes there is triple-counting: The Coast Guard typically turns its interdicted drugs over to Customs, while the seizure may be the result of intelligence information developed by DEA, and all three agencies include the amount in their totals.

   Successful law enforcement efforts, at least in theory, should reduce the available supply of drugs while driving up the price and reducing purity. When the level of purity dips below some hypothetical level but the price remains high, the abuser will supposedly no longer find it worth his or her while to make a purchase. The abuser will either switch to a more readily available chemical— perhaps alcohol—or abandon drug use completely. In fact, successful law enforcement efforts may cause a switch from a less dangerous substance—for example, marijuana—to a more dangerous substance, such as heroin, a situation that apparently occurred when Operation Intercept at the Mexican border effectively choked off supplies of marijuana in 1969. “There was an upsurge in heroin use among urban, white, middle-class high school students shortly after Operation Intercept” ( Zinberg and Robertson 1972 , 210). More recent successful campaigns against marijuana might be causing an increase in the use of alcohol, particularly among adolescents. Increases in law enforcement do not necessarily translate into reductions in supply; a widely heralded (by politicians) 1986, $1.7 billion federal antidrug law resulted in an increase in drug seizures and arrests with no discernible impact on supply ( J. Johnson 1987 ). Successful interdiction might reduce the amount of heroin and cocaine entering the United States, but if demand remains unchanged, underground chemists will be inspired to greater creativity. Indeed, experienced cocaine users cannot tell the difference between cocaine and synthetic substances that mimic cocaine, and heroin addicts often prefer the synthetic opiate fentanyl to the diluted heroin typically available on the streets.

   The structure of the drug market, as was noted in  Chapter 9 , makes it the last refuge of laissez-faire capitalism. The Drug Enforcement Administration ( 2003 ) argues that the “element of risk created by strong enforcement policies raises the price of drugs, and therefore lowers the demand” (7). But how does law enforcement affect the price and use of illegal drugs? Kleiman ( 1985 ) states that the key to analyzing this question “is the response of drug purchasers to increasing drug prices” (69). If there is a reduction in supply and a corresponding increase in price, will the amount of drug consumption remain unchanged? Is demand relatively inelastic to price? If demand is relatively elastic, consumption will decrease as price goes up. This will cause a decrease in the profits of drug traffickers. If demand is inelastic, however, drug law enforcement may actually increase the profits of traffickers, since those who elude arrest and prosecution will reap higher prices. With respect to heroin, Kleiman notes, consumption is likely to decrease in the long run as addicts, unable to keep up with the increase in price, enter drug treatment or find alternative drugs. The issue with respect to cocaine is more difficult. Cocaine has typically been relatively expensive, although the introduction of crack altered the market. Nevertheless, Kleiman argues, an increase in price as a result of law enforcement efforts is likely to increase the profits of cocaine traffickers; it is a market that is relatively impervious to price.

   At the domestic distribution level, successful law enforcement efforts whittle down the number of people involved in drug trafficking. This may leave a void at certain levels of distribution that, in a seller's market, will simply attract new entrepreneurs. Furthermore, the better-organized groups resist and survive law enforcement efforts. Thus, the level of law enforcement vigor and ability determines whether or not certain groups will come to dominate the drug trade and bring a concomitant increase in profits by virtue of oligopolistic (scarcity of sellers) market circumstances. On the other hand, reduced law enforcement allows more groups to remain in business, with a corresponding reduction in profits, resulting from a more competitive market. Under such conditions organizations that are equipped with resources for violence may be tempted to use force to reduce competition.

   Another issue is the argument that the substantial investment in drug law enforcement increases criminality—drug abusers committing crimes to support habits—and diverts resources that could be better utilized to deal with more serious criminality. Police, prosecutors, and judges are occupied with drug law enforcement, and U.S. jails, prisons, and probation and parole systems are overcrowded. Our drug enforcement agents are exposed to great danger, both from a most violent class of criminals and from being around the drugs themselves.

   Our “war” on drugs is really a fight against socioeconomic dynamics that are reputed to be unconquerable: the profit motive and the law of supply and demand.

   In the next chapter, we will examine our policy for responding to drug use.

Chapter Summary

· 1. Appreciate that the single most important factor in drug use is degree of access:

· • The most important precipitating factor in drug use is degree of access—hence the logic of a law enforcement component in prevention.

· • The cost of purchasing drugs can reduce availability and law enforcement efforts can affect the cost of illegal drugs.

· 2. Know that drug law enforcement is constrained by constitutional requirements, jurisdictional limitations, and corruption:

· • The Fourth Amendment and the exclusionary rule are particularly important for drug law enforcement.

· • The federal system of government has a degree of inefficiency surpassing that of most other democratic nations.

· • Proactive law enforcement used to combat drug trafficking is vulnerable to corruption.

· • Corruption is often intertwined with the problem of informants.

· • The legal foundation for federal drug law violations is Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as amended (usually referred to as the Controlled Substances Act (CSA).

· • Conspiracy statutes are valuable tools for prosecuting drug offenders.

· • The Money Laundering Control Act of 1986 made money laundering a federal crime.

· • There are two types of forfeiture proceedings: criminal and civil. Civil forfeiture does not require criminal charges.

· • Civil forfeiture has been criticized for its impact on innocent third parties and as a device for plea-bargaining with drug kingpins.

· • At the local level, it is the low-level street dealer who is most frequently arrested, while federal drug law enforcement seeks to disrupt illicit trafficking organizations.

· • Successful drug enforcement can have unintended consequences.

· 3. Know the federal agencies responsible for combating drug trafficking:

· • In addition to law enforcement, the Drug Enforcement Administration, regulates the legal trade in controlled substances, and manages a national drug intelligence network.

· • Customs and Border Protection agents and Coast Guard personnel are not bound by Fourth Amendment protections that typically restrain law enforcement.

· • The Internal Revenue Service employs the net worth theory to deal with the tax evasion of drug traffickers.

· • The primary responsibility of the Marshals Service relative to drug trafficking is the Witness Security Program.

· • Department of Defense involvement in drug law enforcement is controversial.

· 4. Understand the three categories of street-level drug enforcement:

· • Community-wide policing.

· • Geographically focused policing.

· • Hot spots policing.

Review Questions

· 1. How can law enforcement affect the cost of drug?

· 2. What are the three issues that severely constrain drug law enforcement?

· 3. Why are the Fourth Amendment and the exclusionary rule particularly important for drug law enforcement?

· 4. How does our form of government handicap efforts against drug trafficking?

· 5. Why is proactive law enforcement used to combat drug trafficking vulnerable to corruption?

· 6. What are the problems involved in using informants in drug law enforcement?

· 7. What is the legal foundation for federal drug law violations?

· 8. Why are conspiracy statutes valuable for prosecuting drug offenders?

· 9. What is the advantage of civil over criminal forfeiture?

· 10. What are the criticisms of civil forfeiture?

· 11. In addition to law enforcement, what are the responsibilities of the Drug Enforcement Administration?

· 12. What is the unusual power enjoyed by Customs and Border Protection agents and Coast Guard personnel?

· 13. How does the Internal Revenue Service deal with the tax evasion of drug traffickers?

· 14. Why is Department of Defense involvement in drug law enforcement controversial?

· 15. What is the role of INTERPOL in dealing with drug trafficking?

· 16. What are the categories of street-level drug enforcement?

· 17. What are the advantages of street-level drug enforcement?

· 18. What has been the affect of successful efforts against drug trafficking?

· 19. What are the features of the “drug market intervention initiative” that is the brainchild of David Kennedy?

· 20. What are the unintended consequences of street-level drug law enforcement?

· 21. Why is it difficult to measure success in drug law enforcement?

HAPTER 11 UNITED STATES DRUG POLICY

President Barack Obama signing the 2009 “Family Smoking Prevention and Tobacco Control Act”

After reading this chapter, you will:

· ▸ Know the two basic models for responding to drug use: disease model and moral-legal model

· ▸ Understand the U.S. policy of supply reduction through law enforcement and source country eradication

· ▸ Understand why U.S. efforts against drug trafficking are often secondary to foreign policy considerations

· ▸ Know the practical and ethical issues surrounding the criminalized nonmedical use of drugs during pregnancy

· ▸ Understand the reasoning and effectiveness of statutes authorizing compulsory drug treatment

· ▸ Know why medical marijuana has become a major issue

· ▸ Understand how the measurement of results is a major problem with instituting any changes in policy

Rocky Mountain High

Dating back to the 1970s and celebrated every April 20, the annual pot party known as “4/20” draws large crowds to the University of Colorado, one of the largest marijuana festivals in the nation. Once again, in 2012, “despite a buzz-killing backdrop of federal raids and local crackdowns, marijuana fans celebrated their high holiday in traditional ways: smoking, speaking out and—no doubt—snacking.”

Source:  McKinley 2012 , 11.

Tell It to the Judge

“Inhaled marijuana,” writes New York State Supreme Court Judge Gustin Reichbach, “is the only medication that gives me some relief from nausea, stimulates my appetite, and makes it easier to fall asleep. The oral synthetic substitute, Marinol, prescribed by my doctors, was useless…. I find a few puffs of marijuana before dinner gives me the ammunition in the battle to eat. A few more puffs at bedtime permit desperately needed sleep.” In 2012, Judge Reichbach lost his battle with pancreatic cancer.

Source:  Reichback 2012 , 27.

“  If we cannot destroy the drug menace in America, then it will surely in time destroy us.

—President Richard M. Nixon ( 1971 )

“  Our current drug policies allow avoidable harm by their ineffectiveness and create needless suffering by their excesses.

—Mark A.R. Kleiman, Jonathan P. Caulkins, and Angela Hawken ( 2011 , xxi)

Out of the history that we explored in  Chapter 8 , two basic models were developed for responding to the use of dangerous substances. The first is a  disease model : The abuser is “helpless” and “blameless,” analogous to the cancer or coronary patient. This model defines substance abuse as a disease to be prevented or treated, just like any other public health problem. The second is a  moral—legal model  that defines alcohol and other psychoactive drugs as either legal or illegal and attempts to control availability through penalties. The moral—legal model utilizes three methods to control potentially dangerous drugs:

· ▸ Regulation: Certain substances that may be harmful to their consumers can be sold with only minimal restrictions. These substances are heavily taxed, providing government with an important source of revenue. Alcoholic beverages and tobacco products are subjected to disproportionate taxation, and their sale is restricted to people above a certain age. Special licenses are usually required for the manufacture, distribution, and sale of regulated substances.

· ▸ Medical auspices: The use of certain potentially harmful substances is permitted under medical supervision. The medical profession is given control over legal access to specific substances that have medical uses because when the substances are taken under the direction of a physician, their value outweighs their danger ( J. Kaplan 1983a ). In this category are barbiturates, amphetamines, certain opiates (morphine and codeine), and heroin substitutes, such as methadone and OxyContin.

· ▸ Criminalization: Statutory limitations make the manufacture or possession of certain dangerous substances a crime and empower specific public officials to enforce these statutes. Certain other substances are permitted under medical auspices, but punishment is specified for individuals who possess these substances outside of accepted medical practice. Thus, heroin has no permissible use in the United States—an absolute prohibition—while other psychoactive substances, such as morphine and Seconal (secobarbital sodium), are permissible for medical use but are illegal under any other circumstances.

   The official response to a particular substance—regulation or law enforcement—determines the manner in which the user of that substance will be treated. Thus, the alcoholic is typically viewed according to the disease model, while the user of illegal drugs has the criminal label attached. From the Civil War to the 1920s, the U.S. response to dangerous drugs moved from permissiveness to one of rigid law enforcement—from the public health model to the moral—legal model. The practical effect of this change was “to define the addict as a criminal offender” ( Schur 1965 , 130), leading to the creation of a vast black market in which drug entrepreneurs quickly filled the void left by the withdrawal of lawful sources: “In the 1920s this country had a large number of addicts, but they were not regarded as criminals by the law; in general, they did not commit crimes and conducted their lives much the same way as the nonaddict population did. Clinics and private physicians were free to prescribe maintenance doses. It was the outlawing of the addictive drug that gave rise to an illegal market controlled by organized crime; and it is the exorbitant cost of the outlawed drug that has driven addicts into criminal activity to support their habit” (National Council on Crime and Delinquency 1974, 4).

   Drug policy in the United States has been guided by “commonly shared simplifications”—in particular, the belief that “drug problems are largely attributable to morally compromised or pathological individuals who were not properly inculcated in childhood with normal American values such as self-control and respect for the law. These individuals must be disciplined and punished by authorities in order to “deter them from involvement (for pleasure or profit) with inherently dangerous, addicting drugs” ( Gerstein and Harwood 1990 , 41).

   Drug use, notes Sykes ( 1967 ), “became defined as a fundamental affront, part of a larger pattern challenging society with an alternative view of a meaningful life.” The wrongdoing of the drug user was “moved into the category of the most serious offense—treason—where the individual forsakes his society for an enemy allegiance” (77). A “clearer case of misapplication of the criminal sanction,” writes Herbert Packer ( 1968 ), “would be difficult to imagine” (333). Post-Harrison Act efforts against certain psychoactive chemicals were based on their potential to harm users. Policy has now come full circle, and it is the user who is the target of vigorous enforcement efforts: “We must focus responsibility and sanctions on illegal drug users” (White House Conference for a Drug Free America  1988 , 9).

Incongruities Between Facts and Policies

Before examining the current policy, we need to return to the first chapter and recall some incongruities. Of the most widely used psychoactive drugs, heroin and cocaine (except for limited topical use) are banned; barbiturates, tranquilizers, and amphetamines are restricted; and alcohol, caffeine, and nicotine products are freely available save for young adults and minors. These inconsistencies make any response to the problem of substance abuse very difficult. How do you tell the progeny of cigarette-smoking, coffee- and alcohol-drinking, sedative-using parents that drugs should not be used for recreational purposes? “Someone who smokes tobacco is a smoker, but someone who smokes marijuana is a drug user” ( Whiteacre 2005 , 9). Therefore, “a major step toward developing sounder policy with respect to drugs would be to use that label for alcohol and nicotine (as the scientific literature already does), and to make an augmented Office of Drug Control Policy responsible for coordinating federal policy toward alcohol and nicotine as part of the overall national drug control strategy” ( Reuter and Caulkins 1995 , 1061).

   To what extent does knowledge actually affect drug policy? Although nicotine and alcohol are clearly dangerous psychoactive chemicals—drugs—semantic fiction portrays them otherwise. Statutory vocabulary and social folklore have established the fiction that alcohol and nicotine are not really drugs at all ( National Commission on Marijuana and Drug Abuse 1973 ). Furthermore, as the National Commission on Marijuana and Drug Abuse points out, to do otherwise would be inconsistent with our stated policy goal of eliminating drug abuse—an admission that we can never eliminate the problem. Joseph Gusfield ( 1975 ) suggests that we distinguish between scientific knowledge—the body of facts and theories related to drug use— and political knowledge, which concerns public attitudes toward drug use, including scientific knowledge. Zinberg ( 1984 ) states that in the field of drug use, the truth will not necessarily set one free. The scientific truth he notes, is that not all psychoactive drug use is misuse; but because this concept contravenes formal social policy, those who present this message run the risk that “their work will be interpreted as condoning use” (200).

   Our response to easily abused substances is not based on the degree of danger inherent in their use. Indeed, measured on any dimension, alcohol is a more serious drug of abuse than marijuana, though this is not reflected in the U.S. legal system. And while marijuana smokers are subject to arrest and prosecution, people who smoke tobacco are left free of restraint save for the inconvenience posed by smoking-related cancer and emphysema. In 2006, it was determined that for some unknown reason, smoking marijuana does not increase the risk of lung cancer ( Bloomberg News 2006 ). Furthermore, many dangerous substances, such as amphetamines, barbiturates, and a variety of sedatives, were actively promoted for use in dealing with anxiety, stress, obesity, or insomnia. Famous abusers of these substances, such as Marilyn Monroe and Elvis Presley, who have been commemorated on our postage stamps, are representative of a large abusing population that is not subjected to arrest and imprisonment. The pushers of these substances—the drug companies and their willing partners in the medical profession—are not arrested or prosecuted.

   That some drugs are outlawed while others are legally and widely available is better understood in terms other than those of science or medicine: in terms of the tobacco industry, the alcoholic-beverage industry, the drug-manufacturing industry, the dietary supplements industry, and, as seen in  Chapter 8 , prejudice and racism. The 1994 Dietary Supplement Health and Education Act allows manufacturers to market an array of products, many of them ephedra-based, with claims that these products will boost energy levels, improve your sex drive and performance, help you to lose weight, and cause you to gain muscle. “The law states that you don't have to prove natural supplements are safe or effective before you market them; the government has to prove that they aren't after the fact” ( O'Keefe and Quinn 2005 , 88). Ironically, one of the major purveyors of these products is a multimillionaire and convicted drug dealer. In 2004, supplements containing ephedra were banned by the Food and Drug Administration.

   In addition to political contributions, the purveyors of legal psychoactive substances are able to protect their interests through advertising and employment of media specialists. In fact, the public's knowledge of and response to the “drug problem” is mediated through newspapers and television. Frightening news stories create pressure for more vigorous drug enforcement, which increases drug-fighting budgets, which yield more arrests ( L. G. Hunt 1977 ). The resulting statistics are then viewed as proof of a growing drug problem. “Evidence,” in fact, “has little bearing on the kind of moral beliefs many people hold: that the use of psychoactive drugs is wrong, and their sale more wrong; or that government intrusion into the drug use decision is wrong, and harsh sanctions against possession are also wrong” ( Caulkins et al. 2005 , 2).

   The “volume of attention generated when the national press converges on a story, like drugs, virtually demands a political response. In their haste, these [politicians'] reactions may not always be carefully considered” ( Merriam 1989 , 31). Convergence occurs when media sources discover an issue and respond to each other “in a cycle of peaking coverage, before largely dismissing the issues” ( Reese and Danielian 1989 , 30n). In 1989, for example, President George H. W. Bush made a major television address during which he declared “war on drugs.” For the next week, network news averaged four stories each evening on drugs, and an opinion poll indicated that 64 percent of the public viewed drugs as America's most important problem. A year later, that figure had fallen to 10 percent as new problems received presidential and media attention ( Oreskes 1990 ).

   On November 17, 1985, crack cocaine was mentioned for the first time in the major media, in the New York Times. In less than eleven months, every major news source had stories about crack—more than 1,000 of them—capped by specials on CBS and NBC ( Inciardi et al. 1996 ). This set off an ill-conceived and, some argue, racist legislative response. Under federal law, for purposes of punishment a given amount of crack is equivalent to 100 times that amount of powdered cocaine. In the twenty-first century, it would be difficult to find mention of crack in the major media.

   With these incongruities serving as a backdrop, let us critically examine U.S. drug policy.

Supply Reduction Through the Criminal Sanction

In theory, in a free-market economy reducing the supply of a product will drive up the price and thus reduce demand and consumption. But in the drug economy an increase in price might just raise the revenue for traffickers because there is no significant decrease in consumption. The evidence is that there is not a single documented instance in which one or a succession of high-level drug cases coincided with a substantial reduction in consumption in a city ( Kleiman 1989 ). DiNardo ( 1993 ) failed to find “any significant effects of law enforcement on the price of cocaine faced by users” (63). Enforcement success may simply eliminate the less-organized criminal distributors, resulting in an increase in the profits of criminal organizations that are strong enough and ruthless enough to survive.

Unintended Consequences

Regardless of what we think we are trying to do, when we make it illegal to traffic in commodities for which there is an inelastic demand, the effect is to secure a kind of monopoly profit to the entrepreneur who is willing to break the law. In effect, we say to him: “We will set up a barrier to entry into this line of commerce by making it illegal and, therefore, risky; if you are willing to take the risk, you will be sheltered from the competition of those who are unwilling to do so. Of course, if we catch you, you may possibly (although not necessarily) be put out of business; but meanwhile you are free to gather the fruits that grow in the hothouse atmosphere we are providing for you.”

Source:  Packer 1968 , 279.

   An alternative strategy, focusing on lower-level dealers, presents additional problems: the political problem of going after small wrongdoers while largely ignoring the big ones ( Kleiman 1985 ) and the practical problem of the cost of arresting, prosecuting, and imprisoning large numbers of people. This approach was the mainstay of the so-called (Governor) “Rockefeller Laws” in New York during the 1970s. As a result, the time needed to dispose of drug cases nearly doubled between 1973 and 1976, and by mid-1976 the system was approaching collapse. Ironically, research found that the use of drugs increased during this time, as did drug-related crimes such as burglary, robbery, and theft (Joint Committee on New York Drug Law Evaluation  1977 ).

   In 1987, the strategy suggested by Kleiman caused New York City to establish special courts to rapidly dispose of felony drug cases through plea bargaining because the regular criminal courts were being flooded with arrests of street-level drug dealers. Because of the volume, it was taking six to twelve months to dispose of a case, which created a chaotically overcrowded situation on Riker's Island, the city jail for people awaiting trial ( Raab 1987 ). In the decade from 1981 to 1991, the average daily jail population in New York City increased 170 percent. The New York Times concluded that “New York City's war on drugs has resulted in so many arrests that there are simply not enough prosecutors, judges, Legal Aid lawyers or probation officers to give adequate attention to each of the thousands of cases, let alone courtrooms to try the suspects in or jail cells to hold the convicts” ( “Drug Arrests and the Courts' Pleas for Help” 1989 , E6).

   Other states followed New York's lead, with similar results. The number of people who were convicted of drug felonies in state courts increased almost 70 percent in the two-year period from 1988 to 1990. In Cook County (Chicago), Illinois, the chief criminal court judge stated that drug cases were overwhelming the county's court system ( O'Connor 1990 ). In the federal courts the number of drug arrests so backed up the system that judges were unable to attend to civil cases, increasing delays despite a drop in the number of civil filings. By 2004, federal prisons were operating at 140 percent of capacity, and state prisons were operating at 115 percent of capacity (Prisoners in 2004,  2005 ). Jails throughout the United States are being operated severely over capacity, and any strategy that causes a significant increase in the inmate population could be disastrous. Indeed, ridding prisons of (supposedly) nonviolent drug offenders is frequently offered as a remedy for prison overcrowding.

   The General Accounting Office ( 1991 ) found that overcrowded jails and prisons, the result of increased drug arrests and prosecutions, resulted in more offenders being placed in the probation and parole systems, which, in turn, has generally decreased the level of supervision of probationers and parolees as a result of excessive caseloads. It also led to emergency prison release programs and an increase in plea bargaining—signs of a system spinning its wheels. In 1996 and again in 1998, Arizona voters took matters into their own hands and enacted propositions that mandate treatment instead of imprisonment for drug offenders ( Egan 1999b ).

How about Sealing Our Borders?

At the end of 2011, an inmate at Tucson, Arizona's Santa Rita prison complex, who was serving a sentence for several armed robberies, died of a heroin overdose. If you can't keep heroin out of a maximum security prison … And, of course, methamphetamine, marijuana, and a whole list of prescription drugs, do not have to be smuggled into the country.

Source:  Piazza 2011 .

A Racist Drug War?

A study conducted by USA Today revealed that African Americans are four times as likely as whites to be arrested on drug charges, even though both groups use drugs at about the same rate; and African Americans are more likely to be imprisoned for drug charges than are non-Hispanic whites ( Meddis 1993 ). A more recent study found that black men are nearly twelve times as likely to be imprisoned for drug convictions as adult white men ( Eckholm 2008b ). “African Americans comprise approximately 12% of the United States population, 13% of drug users, 35% of drug arrests for possession, 55% of drug convictions and 74% of prison sentences” ( Chambers 2011 , 3–4). Blacks in New York are seven times more likely to be arrested than whites for simple marijuana possession; Latinos are four times more likely ( Dwyer 2009 ). Not only are members of minority groups more likely to be incarcerated for drug offenses, they are punished with longer sentences than their white counterparts ( Office of National Drug Control Policy 2012 ).

   Cocaine, in the form of crack, is most likely to be used and sold by African Americans, while powdered cocaine is often used and sold by whites. Under federal statutes, “It takes one hundred times the amount of powder cocaine to equal the same sentence as crack cocaine” (Illicit Drug Policies,  2002 , 134). A cocaine dealer would have to sell $75,000 worth of the drug in powdered form to get the same mandatory five-year federal sentence that a crack dealer would receive for selling $750 worth. And “crack is the only drug that carries a mandatory prison term for possession, whether or not the intent is to distribute” ( C. Jones 1995 , 9).

   In 1991, the Minnesota Supreme Court found unconstitutional and discriminatory against African Americans a state law providing twenty years in prison for crack possession but only five years for possession of powdered cocaine. In 1988, of the people charged with crack possession in Minnesota 96.6 percent were black, while those charged with possessing cocaine hydrochloride were 79.6 percent white (State v. Russell 477 N.W.2d 886). The 2010 Fair Sentencing Act reduced the disparity in federal sentencing for future crack cases.

   The war on drugs also exacerbates racial disparities related to health and well-being in minority communities: Federal law prohibits ex-prison inmates from receiving any federal benefits for five years if their conviction was for drug possession or drug trafficking; they are also barred from Temporary Assistance to Needy Families and food stamps; and they become ineligible for one year after conviction, two years after a second conviction, and indefinitely after a third for federal education assistance (“How the War on Drugs Influences the Health and Well-Being of Minority Communities” 2001).

Another Victory in the War On Drugs

In Texas, the single, thirty-year-old, African-American mother of two, was arrested in a drug sweep. Maintaining her innocence, she rejected a prosecutor's offer of probation in exchange for a guilty plea. After a month in jail, fearing for her children, she agreed to the plea deal, received ten years probation, and was ordered to pay $1,000. Destitute, and now with a felony record, she was barred from receiving food stamps and evicted from public housing.

Source:  M. Alexander 2012 .

Would Changing the Penalties Help?

What about a policy of incarceration for only the most serious criminal offenders, such as robbers, among the drug-abusing population? Unfortunately, this is not feasible according to a study by Johnson, Lipton, and Wish ( 1986a ): “Existing criminal justice practices would fail to detect most persons who actually are robber-dealers” (187). Furthermore, their research found that none of the high-rate addict-robbers were ever arrested for robbery. This brings into question the oft-stated strategy of reducing the prison population by releasing “non-violent” drug offenders. In fact, “less than 1 percent of self-reported crimes by cocaine-heroin abusers result in an arrest” ( 1986b , 4).

   In a report to the Ford Foundation, Wald and Hutt ( 1972 ) recommended reducing penalties to a fine or abolishing them completely for those possessing drugs for personal use: “If this were done, drug users—but not drug traffickers—could then be handled on a public health and social-welfare basis…. Law-enforcement efforts would, and in our opinion should, continue, but they would be directed at illegal distribution. And illegal drugs would remain subject to confiscation wherever found” (37). In Switzerland and the Netherlands, there is an unofficial policy of tolerating small-time drug sellers and their customers, as long as they do not become public nuisances (discussed in  Chapter 12 ). At best, states Kleiman ( 1989 ), law enforcement efforts can prevent the “effective decriminalization” of drugs, the point at which trafficking “is so open and flagrant that demand increases because the apparent social disapproval is reduced” (xviii).

   Increasing penalties for drug trafficking seems an unrealistic strategy because sentences for trafficking are already high—forty years for a second offense—and because capital punishment (for drug-transaction-related murders) has become part of the federal effort against drugs. Severe penalties encourage in traffickers the mindset that they have little or nothing to lose by using violence in their attempts to avoid arrest and prosecution.

   China, Iran, Malaysia, and Vietnam execute drug dealers, but the impact of this policy is questionable. Although Malaysia imposes the death penalty for anyone who is found trafficking in heroin or marijuana, the substances are readily available even to foreigners traveling through that country. The People's Republic of China routinely executes drug traffickers who are found in possession of a pound or more of heroin. Every June 26, on United Nations “International Day against Drug Abuse,” China executes dozens of drug traffickers. Despite the executions drug trafficking continues to thrive, particularly in Yunnan and Guangdong provinces in southern China, and the country has become a transshipment point for Golden Triangle and Golden Crescent heroin ( French 2004 ). Draconian attempts to deal with opium and heroin use in Iran have proven unsuccessful. While traffickers are routinely hung, in contrast to the United States, Iran also uses a harm reduction approach to heroin addicts: needle distribution, methadone maintenance, and an extensive network of government-supported treatment programs ( Fahti 2008 ).

Improving Drug Law Enforcement

In theory, if law enforcement success drives up the price of drugs significantly and/or the amount available for consumption falls off considerably, users will seek treatment or give up their drug-using habits. Indeed, research has found that the amount of heroin use is related to price ( Bach and Lantos 1999 ). However, when drug users are unable to secure their preferred substance they can switch to more available substances, such as methamphetamine instead of cocaine, or OxyContin instead of heroin. As long as demand remains strong, successful interdiction will encourage the production of domestic inorganic (agonists) depressants and stimulants.

   In 1995, the DEA seized of large quantities of precursor chemicals that disrupted the methamphetamine supply chain. As a result, the price of methamphetamine in California tripled while purity decreased from 90 to 20 percent. Within four months, however, the price returned to its original level and within eighteen months so did purity (RAND Drug Policy Research Center  2009 ).

Cost Ineffectiveness

While a modest amount of drug enforcement drives up prices a lot, more enforcement does not drive them up much further, a phenomenon known as “diminishing returns.”

Source:  Kleiman, Caulkins, and Hawken 2011 .

   Cowan ( 1986 ) argues that federal efforts against cocaine led to the development of crack: “The iron law of drug prohibition is that the more intense the law enforcement, the more potent the drug will become.The latest stage of this cycle has brought us the crack epidemic” (27). Free-market conditions provide an incentive for traffickers to improve the attractiveness of their product. Fagan and Chin ( 1991 ) point out that crack was the subject of an ingenious production and marketing strategy. A glut of cocaine forced prices down in 1983, but even lower prices did not keep up with production: “At this point, a new product was introduced which offered the chance to expand the market in ways never before possible: crack, packaged in small quantities and selling for $5 and sometimes even less—a fraction of the usual minimum for powder—allowed dealers to attract an entirely new class of consumers. Once it took hold this change was very swift and very sweeping” ( T. Williams 1989 , 7).

   Crack never became a mainstream drug and by 1990 the epidemic had peaked, but heroin use increased. Because heroin had lost its dominant market position to cocaine, heroin purity levels increased substantially, drawing in new users who can snort or smoke the substance instead of injecting it intravenously in the more traditional manner. But the “crack scare” of the 1980s left in its wake new laws and greater use of imprisonment, adding significantly to an already overcrowded prison system ( Egan 1999a ). As Musto ( 1998 ) notes: “History shows that excessive use of a drug at one time does not mean that such a high rate will continue indefinitely; the drug may fade in esteem and usage, even to the vanishing point. Reasonable drug policies must take into account the long-term perspective. We should avoid hastily surrendering to defeat at a time of extensive use nor declare victory after a long and deep decline in drug use” (58).

   Reducing the market for illegal drugs can have unpleasant outcomes because “competition will increase among dealers, perhaps violently. In addition, because selling cocaine has been the primary source of earnings for poor adult males dependent on cocaine, these individuals may turn to other forms of crime to finance their continued consumption, relying more on muggings, burglary, and shoplifting for income, just as heroin users/dealers have done for many years” (RAND Drug Policy Research Center  1992 , Internet).

Good News, Bad News

In 2005, Iowa, like nearly thirty other states, enacted a law restricting the sale of cold medicines whose pseudoephedrine can be used to make methamphetamine. As a result, during the first seven months there was a significant decrease in home-cooked methamphetamine; lab seizures went from 120 to 20, and whereas $2.8 million dollars had been spent in 2004 on treating people at the University of Iowa Burn Center whose skin had been scorched by toxic chemicals, there was a virtual absence of victims in 2005. But the bad news: more methamphetamine-dependent patients were under treatment and the seizure of the drug increased as the home-made powdered version was replaced by the more powerful Mexican crystal methamphetamine.

Source:  Zernike 2006a .

   Wisotsky ( 1987 ) argues that our law enforcement efforts have failed and will continue to do so. He certainly has the lessons of history and classical economics on his side. “Stop talking about winning drug wars,” states Trebach ( 1987 ). “In the broadest sense, there is no way to win because we cannot make the drugs or their abusers go away. They will always be with us. We have never run a successful drug war and never will” (383). Insofar as drug abuse is caused by societal deficiencies in education, housing, and other quality-of-life-variables, the more we expend on law enforcement, the less resources will be available to deal with these social ills, which continue to foster greater drug abuse. Not only are we spinning our wheels in the mud, but the faster we go, the deeper the hole becomes.

   We must recognize a troubling aspect of drug trafficking: It operates according to the powerful forces of free-market capitalism. It is paradoxical that politicians who argue that capitalism defeated Communism in Eastern Europe also talk of defeating the business of drugs. They fail to acknowledge that these same forces operate in the drug trade— and that government cannot compete effectively with the free market. As infamous Cali Cartel leader Gilberto Rodriguez Orejuela pointed out: “Economics has a natural law: Supply is determined by the demand. When cocaine stops being consumed, when there's no demand for it … that will be the end of the business” ( Moody 1991 , 36).

Supply Reduction by Controlling Drugs at Their Source

Attempting to control drugs at their source has had unintended consequences: displacement—the “balloon effect”—and human rights violations. The successful effort to force Turkey to curtail its production of opium in the 1970s resulted in a concomitant rise in opium production in Mexico and Southeast Asia. Mexican antidrug efforts led to a rise in poppy production in neighboring Guatemala, whose government is ill equipped to respond to the problem. Crackdowns in Colombia succeeded in displacing the problem into other countries: Ecuador and Brazil now have cocaine-processing laboratories; Argentina, Uruguay, and Chile have emerged as major money-laundering centers; and drug-related corruption scandals have hit Argentina and Venezuela, which, along with Chile, serve as major cocaine transshipment centers.

   Bolivia reduced coca cultivation by more than half, but at a price: According to the Human Rights Watch, pressure on the government of Bolivia to deal with coca cultivation led to widespread trampling of civil rights and physical abuse of citizenry ( Vivanco 1995 ). In response to declines in these source countries, Colombian wholesalers who bought Bolivian and Peruvian coca increased domestic production ( Krauss 1999a ).

   Coca production in Colombia has more than doubled from 1995 to 2000; the country is now the source of more than 500 tons of cocaine a year, 90 percent of the world's supply. The breakup of the powerful Colombian Medellín and Cali drug cartels spurred coca cultivation in more remote regions of the country and resulted in alliances between new drug gangs and leftist guerillas. Added to this volatile mix are right-wing paramilitary forces that, like their left-wing enemies, are supported by the drug trade. “Feeling relatively safe on their native soil, native coca-growing syndicates have invested heavily in developing more potent strains, some of which can be harvested in as little as 60 days” ( Rohter 2000b , 1). Colombian syndicates have achieved extraordinary levels of efficiency in extracting cocaine from their coca crops. Higher-yielding varieties of coca are being grown in parts of Colombia. Likewise, Colombian laboratory operators became more efficient in processing coca leaf into cocaine base than they had been previously (U.S. Department of State  2000 ).

   After Congress approved a Clinton administration allocation of $1.6 billion to help the Colombian government fight drug traffickers an editorial in the Chicago Tribune (March 12, 2000) argued: “This policy threatens to entangle the U.S. in a decade-old foreign guerilla war while doing nothing to dampen the engine that ultimately drives narcotrafficking: America's roughly $50 billion a year appetite for illicit drugs” (18). The editorial, after noting the involvement of the Colombian army and its right-wing paramilitary allies in massive human rights violations, stated: “It would be repugnant to funnel American aid to a foreign army with such bloody credentials.” And “the latest chapter in America's long war on drugs—a six-year, $4.7 billion effort to slash Colombia's coca crop—has left the price, quality and availability of cocaine on American streets virtually unchanged” ( Forero 2006 , 1). 1

   There is one immutable rule in the drug business: As long as demand remains strong, successful efforts against it at the source level will shift cultivation to a new location. This is what happened in Peru in 2002. In addition to shifting much production to Colombia, a tightened supply has tempted poor farmers in virgin areas to begin cultivating coca ( Forero 2002 ). With financial support from the United States, Colombia is using more than eighty planes to spray herbicide on more than 1 million acres of coca and poppy plants—five planes have been shot down. Nevertheless, cocaine prices in the United States remained stable, and purity improved ( Brinkley 2005 ). An editorial in the New York Times (May 27, 2005) concluded that “Forcible crop eradication moves the problem around, enriches traffickers by raising the price of their holdings, and creates turmoil in rural areas” (22).

   In Peru and Bolivia, inhabitants of coca-growing areas are strongly opposed to U.S.-inspired efforts to eradicate their most important cash crop, and both countries face Marxist insurgencies that are particularly strong in these remote regions. Unfortunately, in addition to providing a livelihood for impoverished Bolivian farmers, cocaine brings into Bolivia more money than all legal exports combined.

   In Peru's Upper Huallaga Valley, which extends for 200 miles along the Huallaga River, an estimated 60,000 families depend on coca as a cash crop for their survival. Large-scale eradication carries with it the risk of social convulsion and resentment that Marxist guerrillas exploited during the 1980s ( Riding 1988 , 6). Coca, by 1990, was Peru's largest export, earning more than 1 billion dollars a year and with as many as 1 million of the country's 21 million citizens involved in the trade ( Massing 1990 ). Under President Alberto K. Fujimori, 2  Peruvian armed forces shot down planes suspected of transporting drugs—about twenty-five aircraft met this fate. This strategy succeeded in breaking the “air bridge,” and when the price of coca leaf dropped more than 60 percent in 1995, farmers began abandoning the crop. With U.S. help, Peruvian officials began teaching farmers to raise coffee instead of coca. By 1999, however, traffickers had reopened some air routes and had replaced others with river, road, and sea channels, once again making coca again profitable, and the crop rebounded ( Krauss 1999b ). Government anti-coca efforts in Bolivia left thousands of Indian farmers without a source of income and helped to generate violent protests that left several soldiers, police officers, and farmers dead ( Associated Press 2000b ).

   “Not only is coca fully integrated into Andean society but it is also an integral part of the region's ecosystem—a stubborn and dismaying biological fact impeding those who would like to make it disappear. As a cultivated plant, coca is nearly ideal. It has few predators and pests…. The plant will grow in soils too poor and on slopes too steep to support other crops, will live for forty years or more, and will tolerate many harvests a year” ( Weil 1995 , 72).

   Wisotsky ( 1987 ) states that “in both Peru and Bolivia, the failure of coca control is not a temporary aberration but a function of culture, tradition, and the weakness and poverty of underdevelopment. These basic social conditions render effective enforcement against coca impossible. Widespread corruption in the enforcement agencies, the judiciary, and elsewhere in government is endemic. Indeed, the central governments do not necessarily control major portions of the coca-growing countryside, where the traffickers rule like feudal lords” (157). Participation in the illicit cocaine economy, writes Morales ( 1986 ), “is inevitable. Not only is the natives' traditional way of life intertwined with coca, but their best cash crop is the underground economy for which no substitute has yet been provided” (157).

   In 1999, thirteen people, including jurists, doctors, artists, religious leaders, and three former Latin American presidents—Belisario Betancur of Colombia, Violeta Chamorro of Nicaragua, and Nobel Peace Prize—laureate Oscar Arias of Costa Rica—signed a letter stating that the U.S.-led military-style war on drugs has failed and should be changed to focus more on ending the demand for drugs and drug money. “The escalation of a militarized drug war in Colombia and elsewhere in the Americas threatens regional stability, undermines efforts towards demilitarization and democracy and has put U.S. arms and money into the hands of corrupt officials and military … units involved in human rights abuses. It is time to admit that after two decades, the U.S. war on drugs—both in Latin America and in the United States—is a failure” ( Jelinek 1999 ).

   In 2002, President George W. Bush met with the Bolivian president at the White House. The Bolivian leader promised President Bush that he would press ahead in his campaign to eradicate the coca crop but needed more U.S. assistance to help ease the impact on farmers. Otherwise, Gonzalo Sánchez de Lozado stated, “I may be back here in a year seeking political asylum.” Mr. Bush laughed and wished him luck. The following year, Mr. Lozado was living in exile in the United States after having been ousted by a popular uprising ( Rohter 2003 ). In 2005, Bolivia elected a leader of cocalero movement, coca growers opposed to U.S. eradication efforts.

Crop Eradication or Substitution

Crop substitution programs have been part of our effort to control drugs at their source but have met with only limited success. As long as demand remains high, the price offered for poppy or coca will be many times that received for conventional crops. There are other problems: In 1991, the leader of a Peruvian coca growers association who had agreed to a crop substitution program was murdered, reputedly by corrupt government officials who earned money from the cocaine business ( Strong 1992 ).

   Attempts to eradicate the crop by cutting or burning result in healthier and more bountiful growth, and uprooting coca plants causes the soil to become unproductive for as long as eight to ten years ( Morales 1989 ). An eradication program in the Upper Huallaga Valley was established with U.S. funding in 1982, but about forty of its workers were eventually murdered. The United States subsequently suspended the program ( Massing 1990 ).

   An alternative is the use of aerial herbicides that are either sprayed or dropped as pellets and that melt into the soil when it rains. The United States has been conducting research on a variety of environmentally safe herbicides. The most successful herbicides, however, kill many species of plants, including crop plants, and remain in the soil, affecting future plantings. Environmentalists have raised objections to the use of herbicides, and the companies that produce them are concerned about potential liability and fear that their employees in South America could become targets of retribution by trafficking organizations ( Riding 1988 ). Furthermore, McIntosh ( 1988 ) has found that a “single genetic mutation can give rise to complete resistance in a similar herbicide. This implies it may be necessary to continually spray different classes of herbicides in the future” (26). The human and political dangers inherent in this approach to drug control should serve as a restraining influence.

   Successful eradication and interdiction efforts can affect both availability and price. However, because of the pattern of price markups in the cocaine business, efforts to eradicate crops or supply routes that increase the cost of the coca leaf tenfold add only 5 percent to the retail consumer price, and doubling seizures from importers increases consumer cost by only 10 percent (Passell 1990). “It costs cocaine refiners only 30 cents to purchase the coca leaf needed to produce a gram of cocaine, which sells for about $150 in the United States. Even if the price of the leaves needed for that gram of the finished produce doubled, it would be negligible. And if retail prices don't rise, then consumption in the United States will not decline” ( Reuter 2000 , 29).

   If all of the coca that the producing countries of Latin America have publicly committed themselves to eradicate were actually eradicated, the effect in the United States would be minimal. It is likely that African, Middle Eastern, and Southeast Asian areas would be able to cultivate enough to meet consumer demand in coca indefinitely (as they have done with opium). It should be noted that coca leaf has been grown commercially in Indonesia, Malaysia, Nigeria, Sri Lanka, and Taiwan. Indeed, the crop that is grown in Java and Taiwan contains more than twice the cocaine of the varieties grown in Latin America ( Karch 1998 ). Epstein ( 1988 ) points out that “the entire cocaine market in the United States can be supplied for a year by a single cargo plane” (25). Furthermore, as was noted earlier, curtailing importation without affecting demand provides an incentive for greater domestic efforts: the production of synthetic analogs for cocaine and heroin and stronger strains of marijuana.

   The highly inventive marijuana horticulturists of California are using a new, fastergrowing, highly potent strain that matures in three months (older strains require four months). Cultivation of this new strain has been discovered in the national forests of Northern California. (Growing marijuana on federal lands was made a felony in 1987, punishable by a prison term of up to ten years.) Indoor cultivation of very powerful strains of marijuana has blossomed in the western Canadian province of British Columbia. Although Canadian law is similar to the United States with respect to marijuana, attitudes in British Columbia reflect a different mindset; even wholesale growers receive light penalties, often just fines. Much of the of the province's crop is smuggled into the United States, where it fetches premium prices owing to the high level of its THC.

   In response to law enforcement efforts against imported marijuana, some innovative growers have established elaborate underground farms equipped with diesel-powered lights and ventilation systems. Their use of hydroponic technology—growing plants in water to which nutrients have been added—has helped to make marijuana the number one cash crop in the United States.

Aerial marijuana searches continue to locate illegal farms, but as this photo shows, clever cultivators have gone underground. Innovations can include diesel-powered lights, ventilation systems, and hydroponic technology.

Drug Enforcement and Foreign Policy

There is evidence that U.S. efforts against drug trafficking are often secondary to foreign policy considerations. The Anti-Drug Abuse Act of 1986, for example, requires the president to certify to Congress that producer and transshipment nations have made adequate progress in attacking drug production and trafficking. Without certification a country can lose aid, loans, and trade preferences. Sciolino ( 1988 ) reports that the law has numerous loopholes that have allowed several nations to be certified despite their failure to cooperate in the war against drugs. In 1990, of the twenty-four major drug-producing and drug-transiting countries only four—Afghanistan, Myanmar, Iran, and Syria—were denied certification. At the other extreme, in 1990, the United States turned to the military in Guatemala, a major producer of opium and a leading transshipment point for Colombian cocaine, to take the lead in efforts against trafficking; the Guatemalan military has been responsible for human rights abuses that have plagued the country ( Gruson 1990 ).

   For many years the United States tolerated the drug-trafficking activities of Central American ally General Manuel Noriega. When his politics took on a decidedly anti-U.S. tone, in 1988 the general was indicted and apprehended, following the “Operation Just Cause” invasion of Panama by the U.S. military. (For a discussion of Noriega, his relationship with the United States, and drug dealing, see  Dinges 1990  and  Kempe 1990 .) According to Thomas A. Constantine, retired director of the DEA, the Clinton administration was more concerned about trade and other economic issues in its relationship with Mexico than with corruption and drug trafficking ( Golden 1999 ).

   Andreas and his colleagues (1991–1992) noted that “after more than a decade of U.S. efforts to reduce the cocaine supply, more cocaine is produced in more places than ever before. Curiously, the U.S. response to failure has been to escalate rather than reevaluate…. The logic of escalation in the drug war is in fact strikingly similar to the arguments advanced when U.S. counterinsurgency strategies, undercut by ineffective and uncommitted governments and security forces, were failing in Vietnam: ‘We've just begun to fight.’ ‘We're turning the corner.’” Therefore, because failure can easily justify further escalation, the question is asked “how do we know whether we are really turning the corner or simply running around in a vicious circle?” (107).

Demand Reduction by Criminal Prosecution for Fetal Liability

The prosecution of drug-using pregnant women for fetal endangerment, delivering drugs to a minor, or child abuse dates back to the end of the 1980s, when drug abuse was high in the political consciousness of elected officials and an increasing number of “drug babies” were being reported. It is estimated that about 350,000 infants annually are exposed prenatally to some form of illegal drug ( Nolan 1990 ). Prosecution is sometimes used to coerce women into drug treatment, although drug treatment programs might not be readily available and those that are might be unwilling or unable to provide for pregnant clients.

Substance Abuse and Pregnancy

· • Fifteen states consider substance abuse during pregnancy to be child abuse under civil child-welfare statutes, and three consider it grounds for civil commitment.

· • Fourteen states require health care professionals to report suspected prenatal drug abuse, and four states require them to test for prenatal drug exposure if they suspect abuse.

· • Nineteen states have either created or funded drug treatment programs specifically targeted to pregnant women, and nine provide pregnant women with priority access to state-funded drug treatment programs.

· • Four states prohibit publicly funded drug treatment programs from discriminating against pregnant women.

Source: Guttmacher Institute.

   The first woman convicted for delivering a controlled substance to her fetus, in Florida in 1990, was sentenced to a year in a drug treatment residential program and fourteen years probation; her conviction was upheld by a state appeals court the following year but was later voided by the Florida Supreme Court ( Lewin 1991 ,  1992 ). In 1991, the Michigan Court of Appeals ruled that a woman who took crack hours before giving birth could not be charged with delivering cocaine to her son through the umbilical cord. In response to the ruling, the Muskegon County prosecutor defended his decision to charge the woman: “This is a major health care crisis and we must use whatever means we can to reach a solution” ( Wilkerson 1991 , 13). Health care officials who supported the woman expressed fear that prosecuting drug-using pregnant women will drive them away from prenatal care. Courts have dismissed similar cases in Maryland, New Mexico, North Carolina, Ohio, and Florida ( Lewin 1991 ;  Nossiter 2008 ). In Alabama, however, women have been successfully prosecuted for using drugs while pregnant ( Nossiter 2008 ;  Calhoun 2012 ).

   Despite considerable concern about the high rate of cocaine use among pregnant women, studies have failed to find a homogeneous pattern of fetal effects, and there is little consensus on the adverse effects of the drug ( Finnegan et al. 1994 ). In a study of birth outcomes and developmental growth of children who were exposed to drugs in utero, infants varied in their birth outcomes, a majority evidencing no significant problems ( Cosden, Peerson, and Elliott 1997 ). An overwhelming majority of women who use cocaine also ingest other drugs, including nicotine, alcohol, marijuana, and opiates, and many suffer from sexual and physical abuse ( Finnegan 1993 ). It is difficult to separate the effects of cocaine from other potential hazards to the fetus. “Women who use cocaine during pregnancy also engage in other behaviors, such as alcohol and tobacco use, that are risk factors for poor pregnancy outcome. In addition, they often live in circumstances that, in themselves, create an environment that fosters poor developmental outcome. To understand the unique or independent effects of cocaine exposure during pregnancy, it is critical to separate factors that correlate with prenatal cocaine use and with the outcome, both at birth and during the postpartum period” ( Richardson and Day 1999 , 234).

   Although we know that women who abuse heroin during pregnancy frequently give birth to infants suffering from neonatal abstinence syndrome—the newborn suffers withdrawal symptoms—we do not know whether there are long-range effects that are directly attributable to the use of drugs; as with cocaine, it is difficult, if not impossible, to separate the effects of drugs from those of poverty and poor prenatal care. Furthermore, the fetus can be endangered by any number of maternal behaviors that are not related to illegal drug use, for example, “too much or too little exercise, an inadequate or harmful diet, or use of cigarettes, alcohol [6,000 to 8,000 born annually with fetal alcohol syndrome], and other [lawful] drugs” ( Nolan 1990 , 13–14). Other risks include the general environment and specific workplace exposures.

   Research has revealed that infants (about 750,000 per year) who are exposed to a high level of cigarette smoke (one pack or more per day) in utero suffer from decreased birth weight, head circumference, and body length. Smokers also experience increased rates of spontaneous abortions and bleeding during pregnancy, and an estimated 5,600 infants die each year as a result of smoking by their pregnant mothers. A study in 1994 revealed that mothers who smoke as few as ten cigarettes a day cause their children under age five to test positive for cancer-causing compounds ( Hilts 1994 ). A study of 4,400 youngsters ages six to sixteen by Kimberly Yoltan of the Cincinnati Children's Medical Center revealed that, after controlling for factors such as race, income, and parents' educational levels, children exposed to high-levels of second-hand smoke have significantly lower test scores in reading, math, and problem-solving than those with the low-levels of exposure as determined by the presence of a nicotine byproduct (cotinine) in their blood ( Szabo 2005 ).

   And what of the liability of the father who is using illegal drugs, alcohol, or tobacco? Research suggests that psychoactive substances are hazardous to spermatozoa ( Finnegan 1993 ), and secondhand smoke has been proven to seriously harm the health of children. Furthermore, what of the societal responsibility to provide adequate prenatal care for all pregnant women? The nonmedical use of controlled substances is only one facet of a significantly greater social problem that will not be resolved by a simplistic recourse to criminal law.

   An equally pressing problem is the cost of providing for infants of drug-abusing mothers: Foster care for one child ranges from $15,000 to $20,000 a year. New York City has responded to this problem by permitting drug-abusing mothers to keep their children at home under the intensive supervision of a social worker ( Treaster 1991 ). A study in Illinois found that although white and African American women show similar rates of illegal drug use during pregnancy, “black women are more likely to be reported to authorities” ( Olen 1991 , Sec. 3: 14). Illinois is one of a number of states where medical personnel are required to report suspected prenatal drug use to authorities. But there are few places in the state to care for babies born with drugs in their bloodstream, so the babies are usually sent home with their mother with some type of outpatient help and monitoring ( Poe and Searcey 1996 ).

No Student Loans for Drug Offenders

U.S. Department of Education regulations, based on a law enacted in 1998, bar students who have been convicted of drug offenses from receiving federal college tuition aid. A first possession conviction bars aid for a year, and a sales conviction will bar aid for two years. Students who are convicted for a second time of possessing drugs will lose aid for two years; those who are convicted a third time lose it permanently. A student who has been convicted twice of selling drugs will lose aid permanently. Some students are able to retain eligibility by completing a drug rehabilitation program. Students must report any drug convictions on federal financial aid forms, including Pell grants and student loans. Students who lie will have to return any aid that they have received and may be prosecuted.

Source:  McQueen 1999 .

Demand Reduction Through Treatment and Supervision

There is a symbiosis between treatment and enforcement: Drug treatment “is demonstratively effective in reducing crime. Law enforcement helps ‘divert’ users into treatment and makes the treatment system work more efficiently by giving treatment providers needed leverage over the clients they serve. Treatment programs narrow the problem for law enforcement by shrinking the market for illegal drugs” ( Office of National Drug Control Policy 2002b , 4). While the core of the U.S. response to drug use centers on enforcement, expanding the availability of treatment might be more productive for reducing demand. There is almost universal agreement that without reduced demand, antidrug efforts will remain ineffective.

   The cost-effectiveness of treatment versus law enforcement is emphasized by Rydell and Everingham ( 1994 ). They argue that $246 million would have to be spent on domestic law enforcement to achieve the same reduction in drug use that could be achieved by spending $34 million on treatment. And no assumption is made about the long-range effect of treatment— abstinence—on the individual abuser: “The cost advantage is so large that even if the after-treatment effect is ignored, treatment is still more cost-effective than law enforcement” (xv).

   It is the possession of controlled substances that constitutes a crime; an addict is not a criminal by virtue of his or her addiction. In Robinson v. California 370 U.S. 660 (1962), the Supreme Court ruled that individuals cannot be prosecuted for “being under the influence” or for “internal possession” of illegal drugs. In that same decision the Court upheld the civil commitment of drug addicts for purposes of treatment (similar to commitment of the mentally ill): “A state might determine that the general health and welfare require that the victims of these and other human afflictions might be dealt with by compulsory treatment, involving quarantine, confinement, or sequestration.”

   Some twenty-seven states have statutes permitting commitment of drug addicts ( J. Kaplan 1983b ). However, only California and New York made extensive use of such statutes; and in both states budgetary and political issues led to the programs being discontinued (New York in 1974) or eviscerated (California). B. Johnson and his colleagues ( 1986a ,  1986b ) argue in favor of mandatory treatment because almost all-objective evidence suggests that drug treatment has an important impact on the criminality of heroin and cocaine users. The cost of such a policy, they note, would be prohibitive unless treatment were on an outpatient basis, a method that they support. Because heroin and cocaine users frequently come into contact with the criminal justice system, all criminal defendants should be subjected to drug tests, which, if positive, should require mandatory treatment. This is the basis for the more than 2,600 drug courts discussed in  Chapter 7 : “Drug courts are premised on the idea that legal coercion to enter drug treatment is an effective means of achieving the benefits associated with treatment programs” and “stiff sanctions associated with noncompliance are used to coerce offenders to enter and remain in treatment” (Drug Courts  2012 ;  Hepburn and Harvey 2007 , 257). Johnson and colleagues argue that drug treatment should be part of any sentence for convicted drug abusers and that postrelease treatment should be a condition of probation or parole supervision, with careful monitoring of urine for at least one year.

   This writer supervised heroin addicts on parole in New York for several years, and their careful monitoring by a parole officer does ensure a high rate of abstinence, at least during the period of supervision. But in any number of jurisdictions supervision in the community is superficial, with caseloads so large that clients cannot be monitored adequately. Offenders who violate the conditions of supervision by using drugs often go unnoticed or unpunished, remaining at liberty until they are arrested again for another drug offense ( Abadinsky 2012 ). A program established in 2004 is a response to this reality. Hawaii's Opportunity Probation with Enforcement (HOPE) seeks to deter drug use (as well as other violations) by probationers with frequent and random drug tests backed up by swift, certain, and short jail stays, usually a few days. A probationer can ask for a drug treatment program. This approach has received a great deal of positive coverage and has proven attractive to other jurisdictions and the National Institute of Justice.

Medical Marijuana

Insofar as there is any widespread interest in drug policy in the United States, the hottest topic concerns medical marijuana. As noted in  Chapter 5 , while marijuana has some use in medicine—for example, to relieve the pressure on the eyes of glaucoma patients, to control the nausea and vomiting that accompany cancer chemotherapy, and to control the muscle spasms of multiple sclerosis patients—its use remains illegal. Since 1982, however, there has been a legally available pharmaceutical for physicians in ophthalmology and cancer treatment: Marinol (dronabinol), which is 98.8 percent pure THC.

   There is some dispute as to whether or not oral THC is as effective as smoking marijuana. In 1989, an administrative law judge for the DEA recommended that marijuana be placed on a less restricted schedule, one that would make it available by medical prescription. The judge called marijuana “one of the safest therapeutically active substances known to man.” The DEA rejected the judge's recommendation ( “U.S. Resists Easing Curb on Marijuana” 1989 ). In 1999, a federally commissioned report by the Institute of Medicine stated that the active ingredient in marijuana is useful for treating pain, nausea, and the severe weight loss experienced by victims of AIDS. But because the smoke emitted by marijuana is even more toxic than tobacco smoke, the report recommended use of the drug only on a short-term basis, under close supervision, for patients who failed to respond to other therapies ( Stolberg 1999 ).

   There is no consensus on the effectiveness of marijuana as a treatment for symptoms of pain, nausea, vomiting and other problems caused by illnesses or their treatment. The lack of medical consensus means that both proponents and opponents of medical marijuana laws “can find research support for their positions, and the medical community has not delivered a clear message to the public” ( Cerdá et al 2012 , 25).

   In 1996, voters approved Proposition 215 that removed criminal penalties for the “seriously ill” in California who possess or cultivate marijuana, and allows growers to cultivate the drug as long as he or she has been designated as a primary caregiver by the patient. By 2011, sixteen states and the District of Columbia had laws permitting medical use of marijuana. In Michigan, for example, patients whose doctors certify they need medical marijuana can grow up to twelve plants or designate a caregiver to grow it for them—anyone over 21 with no felony convictions can serve as a caregiver for up to five patients to whom they can sell marijuana. A 2003 legislative amendment to the California statute permits any resident to own up to half a pound of processed seed which could be purchased from a patient's collective or cooperative. Local governments are permitted to have their own ordinances regulating marijuana, and scores have enacted outright bans ( McKinley 2008 ). Proposition 215 has spawned a growth industry in marijuana for both legitimate medical purposes and apparent recreational use (Samuels 2008). There are an estimated 200,000 persons in California who use medical marijuana and David Freed ( 2012 ) states that because of Proposition 215's imprecise language, “Virtually anybody can consult with one of hundreds of pro-pot physicians across California, claim an ailment, hand over $200, and be issued an annually renewable card that allows them to possess marijuana for medicinal purposes” (32). Time magazine columnist Joel Klein ( 2009 ) received a County of Los Angeles medical marijuana ID card “even though I am healthy” from a doctor after complaining of constant anxiety, insomnia, and headaches (64).

   The economics of cannabis in California is compelling: The amount of space needed to grow a tomato plant will produce between one-quarter to two pounds of marijuana that when wholesaled to a dispensary will bring about $2,000. Getting into the business is facilitated by “Oaksterdam University” in Oakland, a company that teaches people how to grow and sell marijuana ( Kuchinskas 2009 ). In 2012, federal agents from the IRS and DEA raided Oaksterdam, but did not make any arrests.

   The federal government responded to the California referendum by threatening to punish doctors who advise patients that marijuana might ease some of their symptoms by revoking their DEA registration to prescribe controlled substances. Ten doctors and six patients brought a class-action lawsuit challenging that policy, and in 2002 the U.S. Court of Appeals for the Ninth Circuit ruled that the federal policy violated both the free speech of doctors and the principles of federalism. In 2003, the U.S. Supreme Court refused to consider a government appeal of the Ninth Circuit decision. Seven of the nine states in that circuit have laws permitting medical use of marijuana that nevertheless is illegal under federal law. In 2005, the Supreme Court (Gonzales v. Raich, 545 U.S. 1) upheld an appeals court decision (Gonzales v. Raich 352 F.3d 1222) that affirmed the power of the federal government to enforce federal prohibitions against possession and use of marijuana for medical purposes even in the states that permit its use.

   In 2003, five jurors in a federal trial in California that convicted a medicinal marijuana advocate issued a public apology to him and demanded that the judge grant him a new trial. The jurors said that they had been unaware that the defendant, Ed Rosenthal, was growing marijuana for medical purposes when they convicted him on three federal counts of cultivation and conspiracy. The reason for Rosenthal's marijuana cultivation was ruled inadmissible at trial (Murphy 2003). Although the government sought a twoyear sentence, the judge sentenced him to only one day. The government appealed the sentence and in 2006 the conviction was overturned for “juror misconduct.”

   In 2006, in a controversial statement, the FDA denied that any medical benefits result from the use of marijuana. The FDA statement was criticized for being more ideological than scientific; it did not provide any research data and ignored a report by the prestigious National Academy of Science ( Joy, Watson, and Benson 1999 ) that the substance does provide some benefits to certain patients suffering from AIDS and chemotherapy-related nausea and vomiting ( Zernike 2006b ). An editorial in the New York Times ( “Politics of Pot” 2006 , 14) argued that the “Food and Drug Administration, for no compelling reason, unexpectedly issued a brief, poorly documented statement disputing the therapeutic value of marijuana.” In response Henry Miller, a physician and former head of the FDA's Office of Biotechnology, wrote in support of the FDA statement: marijuana smoking cannot be subjected to clinical trials because it does not come in standardized doses and therefore cannot meet the accepted standards for purity, potency, and quality ( H. Miller 2006 ). Permission to conduct clinical trials has been denied by the DEA (Harris 2010).

   In 2009, Attorney General Eric Holder announced that the enforcement policy of the Department of Justice would be restricted to those marijuana traffickers falsely masquerading as medical dispensers. People who use marijuana for medical purposes and those who distribute it to them no longer face federal prosecution if they act in accordance with state law: “It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana, but we will not tolerate drug traffickers who hide behind claims of compliance with state law to mask activities that are clearly illegal”.

   Research into the question of whether or not approval of medical marijuana results in increases in recreational use has had mixed results and is inconclusive ( Cerdá et al. 2012 ). Research indicates that states that legalized marijuana use for medical purposes have significantly higher rates of marijuana use, but correlation does not prove a causal affect.

Measuring the Results of Policy Changes

A major problem with instituting any changes in policy is measurement of results. Increases or decreases in the number of people using illegal substances cannot be measured with any accuracy, and the statistics that are often presented as “data” are usually meaningless. As noted in  Chapter 1 , there are no direct measures of the incidence or prevalence of drug use in the general population--estimates are inferences derived from various data sources.

   Biernacki ( 1986 ) points out that “it cannot be determined with any degree of certainty what effect U.S. drug policy has had on the addict population. What we do know is that the indicators used to estimate the size of the addict population at any one time are unreliable. For example, if the number of hospital emergency room admissions for heroin overdoses drops, does this indicate the effectiveness of police control methods, or the successful treatment of addicts? Or can the drop in admissions be attributed to a change in drug preference? Or to an increase in the number of natural recoveries?” (189). Natural recovery, or the abandoning of heroin use, was discovered among returning Vietnam veterans on a relatively large scale ( Robins 1973 ,  1974 ;  Robins, Helzer, Hesselbrock, and Wish 1980 ). To the extent to which we have been able to measure the effect of U.S. drug policy, the results, though not necessarily the claims, have been unclear. The question remains: Should we be punishing people “simply because we are unable to demonstrate the benefits of not punishing them”? ( Husak and de Marneffe 2005 , 26).

   Now that we have examined drug policy in the United States, the next chapter will examine additional alternatives that have been adopted by European countries.

Chapter Summary

· 1. Know the two basic models for responding to drug use: disease model and moral-legal model:

· • The official response to a particular substance—regulation or law enforcement—determines the manner in which the user of that substance will be treated.

· • Our response to easily abused substances is not based on the degree of danger inherent in their use.

· • Some drug abusers are subjected to incarceration; others have postage stamps in their honor.

· 2. Know the U.S. policy of supply reduction through law enforcement and source country eradication:

· • Enforcement success may simply eliminate the less-organized criminal distributors, resulting in an increase in the profits of criminal organizations that are strong enough and ruthless enough to survive.

· • There is a variety of statistics indicating that the “war on drugs” is often a “war” on blacks.

· • A policy of incarceration for only the most serious criminal offenders is not feasible.

· • Increasing penalties for drug trafficking is unrealistic because sentences for trafficking are already high and there is a lack of evidence indicating that it reduces the supply of drugs.

· • Crack was a response to an oversupply of cocaine.

· • Reducing the market for illegal drugs can have an unpleasant outcome: competition will increase among dealers, perhaps violently; selling drugs is a primary source of earnings for many poor adult males who may turn to other forms of crime.

· • Attempting to control drugs at their source has had unintended consequences: displacement and human rights violations.

· 3. Know that U.S. efforts against drug trafficking are often secondary to foreign policy considerations:

· • Drug legislation, such as the Anti-Drug Abuse Act of 1986, has numerous loopholes.

· • The U.S. government may ignore or downplay drug or human rights violations of economic allies.

· 4. Know the practical and ethical issues surrounding the criminalized nonmedical use of drugs during pregnancy:

· • The prosecution of drug-using pregnant women for fetal endangerment raises practical and ethical issues: lack of treatment programs for pregnant women and discounting fetal harm caused by nicotine and alcohol.

· 5. Understand the reasoning and effectiveness of statutes authorizing compulsory drug treatment:

· • Outpatient compulsory treatment for drug users has proven cost effective.

· 6. Know why medical marijuana has become a major issue:

· • At least sixteen states and the District of Columbia have laws permitting medical use of marijuana.

· • However, marijuana possession remains a federal crime.

· 7. Understand how the measurement of results is a major problem with instituting any changes in policy:

· • The number of drug users cannot be measured accurately.

· • Changes in drug use cannot be fully understood as to whether they are affected by drug policy or nonpolicy factors such as popularity trends, availability, and the like.

Review Questions

· 1. How does the disease model differ from the morallegal model?

· 2. What are the contradictions between scientific knowledge and U.S. drug policy?

· 3. How does the official reaction to a substance determine how the user will be labeled?

· 4. What are some unintended consequences of successful drug law enforcement?

· 5. How does the iron law of capitalism work against effective drug law enforcement?

· 6. Why does the “war on drugs” appear racist?

· 7. Why is a policy of incarceration for only the most serious criminal offenders not feasible?

· 8. Why is an increase in penalties for drug trafficking unrealistic?

· 9. What are the potential adverse reactions to reducing the market for drugs?

· 10. What was the connection between the oversupply of cocaine and crack?

· 11. What are the problems of attempting to reduce the supply of drugs at their source?

· 12. What are the practical and ethical issues raised by the prosecution of pregnant women who use illegal drugs?

· 13. What have been the results of coercive treatment of drug addicts?

· 14. What is the controversy that surrounds medical marijuana?

· 15. Why is it difficult to measure the effects drug use vis-à-vis changes in drug policy?