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Chapter 6Treatment Issues for Special Groups and Settings

Thischapterhastwopurposes:(1)toprovidespecificrecommendationsfortreatmenttailoredtothespecialneedsofeachgroupand(2)
tounderscoretheneedforculturalcompetenceinthetreatmentsetting.Thesecondpointiscrucialtosuccessintreatmentforavarietyof
clients.TheConsensusPanelfeelsstronglythatculturalcompetenceinthetreatmentsettingextendsbeyondracial/ethnicsensitivityto
understandingthemoresofgroupsboundtogetherbygender,age,geography,sexualpreferences,criminalactivity,substanceuse,and
medicalandmentalillnesses.Inaddition,treatmentprovidersneedtounderstandthe"culture"oftheirownorganization,anddetermine
howitmayormaynotbewelcomingtomembersofothercultures.

Thischapterdiscussestreatmentissuesspecifictothefollowinggroups:

Intravenousdrugusers
Gaymen
Methadonemaintenanceclients
Individualswithcooccurringmentaldisorders
Medicallyillclients(e.g.,HIV,TB)
Criminaljusticeclients
Racial/ethnicminorities
Ruralpopulations
Women
Adolescents

Again,treatmentforstimulantusedisordersformembersofanyofthesegroupsmustoccuragainstthebackdropofasolidunderstanding
oftheneedsoftheoneormultiplegroupsinwhichaclientmayclaimmembership.

Intravenous Drug Users


Theinjectingcocaineuser(ICU),likeotherinjectingdrugusers(IDUs),posesamajorpublichealthproblembytransmittingHIVand
hepatitis.Thistransmissioncanoccurinseveralways.First,ICUsmayspreadinfectionsbysharinginjectingequipmentwithotherIDUs.
Second,ICUsmayshareneedleswithotherpopulationsthathavetheirownindependentriskforHIVandhepatitis,suchashomosexuals
andbisexuals.Third,ICUsmaytransmitthediseasetononsubstanceusersthroughsexualcontact.

Prevalence of Injecting Drugs In Stimulant Users


Stimulantandothersubstanceusersmakeuptheestimated1to1.5millionIDUsintheUnitedStates.Approximately85percentofthese
IDUsdonotreceiveanydrugtreatmentservicesonanygivenday(LurieandDrucker,1997).Clearly,IDUswhoarenotintreatmentare
atgreatriskofsufferingthemanyconsequencesofcontinueddruginjection(Metzgeretal.,1993).

TheproportionoftheseIDUswhoareICUscanbebestestimatedbytheNationalAIDSDemonstrationResearch(NADR)program,
sponsoredbytheNationalInstituteonDrugAbuse(NIDA).ThisprogramhasprovidedthemostcomprehensiveprofileofactiveIDUs
notinsubstanceusedisordertreatment.Inthatprogram13,475activeIDUswereassessedfrom28sitesacrossthecountry.Theprimary
injecteddrugswereheroin(28percent),cocaine(21percent),andacombinationofheroinandcocaine(35percent).Theseestimates
appearconsistentwithsometreatmentsamples.Forexample,20percentoftreatmentseekingcocaineusersintheLosAngelesareawere
foundtohaveinjecteddrugsintheprecedingyear(Khalsaetal.,1992).Moreover,94percentoftheseICUsreportedsharingneedles
withotherusers.Together,thesedatasuggestthatsomewherebetween20percentand51percent(cocainealoneandcombinedcocaine
heroinusers)ofIDUsarecocaineusersandthattheseusersshareinjectingequipmentthatisputtingthematriskforHIV,hepatitis,and
otherdiseases.

Pattern of Use and Resulting Consequences


OnefactorthatmayincreaseriskofinfectionamongICUsistheirpatternofuse.Cocaineisfrequentlyusedinintermittentcyclesof
repeatedmultipleusesknownasbinges.Indeed,thispatternofusehasbeenconfirmedinhumanlaboratorystudies(Wardetal.,1997).
Thispatternoftenleadstomorefrequentinjectionsduringabingethanaregenerallyobservedinheroindependentpopulations.Moreover,
injectingcocaineusersoftenshareneedleswithmorepeoplethenthosewhoreportinjectingotherdrugs.

Indeed,thisgreaterfrequencyofinjectionduringabingeappearstohaveasitsconsequenceagreaterlikelihoodofHIVinfection.The
frequentuseofcocaineduringbinges,alongwithgreaterlikelihoodofsharedneedles,hasbeendemonstratedtocausetwicetheriskof
HIVinfectionforICUsthanforotherIDUs(Chaissonetal.,1989Anthonyetal.,1991),and1.5timestheriskofcracksmokers(Kral
etal.,1998).

Reducing Injection Drug Use And Its Consequences


Avarietyofinterventionshasbeenusedtoreducetheconsequencesofinjectiondruguse(forreviewsseeDesJarlaisandFriedman,
1996Sorenson,1991).Theseinterventionsaretailoredtoinjectiondrugusers(IDUs)ingeneral,yettheresultsfromthisresearchare
moreapplicabletoICUs.Itisimportanttonotethateducationalonemaynotbeeffectiveinpreventingtheconsequencesofinjecting
drugs,becausestudieshaveshownthatsuchprogramsincreaseknowledgewithoutchangingbehavior.

EvidenceshowsthatmulticomponentHIVpreventionprograms,whichincludeinstructiononbleachdisinfectionalongwithskillstraining,
counseling,andHIVtesting,reducetheriskoftransmissionovertime(InstituteofMedicine[IOM],1995).However,theseresultshave
notbeensupportedinotherstudies,whichfailedtoprovetheefficacyofbleachdisinfection.Thismaybecausedbyeitherineffective
disinfectionproceduresorinconsistentuseofeffectiveones.The1995ReportonthePreventionofHIVInfection,sponsoredbythe
InstituteofMedicine,recommendsthatbleachdisinfection,whenperformedaccordingtotheguidelinesprovidedbytheCentersfor
DiseaseControlandPrevention(CDC)andtheCenterforSubstanceAbuseTreatment(CSAT),islikelytopreventHIVinfectionfor
IDUswhoshareinjectingequipment.TheIOMreportrecommendsthatIDUsbetrainedineffectiveproceduresandmoreresearchbe
conductedtoidentifythesimplesteffectivedisinfectionprocedures.Expandingthatview,DesJarlaisandFriedmanstatedthat,as
currentlyimplemented,bleachdisinfectionshouldnotbereliedonbyHIVpreventionprograms(DesJarlaisandFriedman,1996).They
suggest,however,thatbleachdisinfectionismoreeffectivethannotandshouldbeperformedwhenequipmentisshared.

Needleexchangeprogramshavebeenimplementedinawidevarietyofcircumstancesthroughouttheworld(Hurleyetal.,1997).The
vastmajorityofstudiesandreportsonneedleexchangeproceduressuggeststhattheyreducetheriskofHIVandhepatitis,andneither
leadtomoreinjectingdrugusenorcreatenewIDUs(Hurleyetal.,1997IOM,1995).

Somepopulationsreceivednonoticeablebenefitfromtheseprograms,however.Forexample,adropinHIVinfectionwasnotseenin
Montreal.OnepossiblereasonforthisisthatMontreal'sneedleexchangeprogramrestrictedthenumberofneedlesaclientcouldobtain
pervisitfewerneedlesthanICUstypicallyuseinthecourseoftheirdruguse.Consequently,clientsturnedtootherneedlesources,
negatingtheeffectoftheprogram.

Althoughthesedatatendtosupporttheuseofneedleexchangeprograms,nocontrolledtrialhasyettobeconducted.TheIOMreport
recommendsthatcommunitiesthatdesiresuchprogramsbepermittedtousethem.Italsorecommendsthatneedleexchangebe
implementedaspartofamulticomponenttreatment,andthatadditionalresearchandevaluationbeconductedtoevaluatetheeffectsof
needleexchangeprograms.

Gay Men
Researchhasfoundthatmenwhohavesexwithmen(MSMs)andwhoabusealcohol,stimulants,inhalants,andothernoninjectionstreet
drugsaremorelikelythannonsubstanceuserstoengageinunprotectedsexandbecomeinfectedwithHIV(Pauletal.,1991,1993,
1994).SexualrisktakingamongMSMs,likethatamongthegeneralpopulation,oftenoccursundertheinfluenceofsubstanceuse,
particularlystimulants.Sexualrisktakingwithinthecontextofsubstanceuseishypothesizedtooccurduetodisinhibitioneffects,learned
patterns(especiallybetweenstimulantuseandcertainhighrisksexualpractices),lowselfesteem,alteredperceptionofrisk,lackof
assertivenesstonegotiatesafepractices,andperceivedpowerlessness(Pauletal.,1993).

Alternatively,sexnetworksandsexualmixingpatterns(Rentonetal.,1995)mightbetterexplainthehigherriskofHIVinfectionrelated
tosubstanceabuseamongMSMs.AssuggestedbyRentonandcolleagues,MSMsubstanceusersmayformtightlydefinedgroups
characterizedbyhigherHIVseroprevalencerates,highersexualmixing,greaterinjectiondruguse,andmoretradingsexformoney,
food,anddrugs.Thesefactors,ratherthanthesuggestedlinksbetweensubstanceuseandhighrisksex,wouldthereforeaccountfor
higherHIVrisksamongMSMsubstanceusers.Regardlessofwhichhypothesisbetterexplainstheconnectionbetweensubstanceabuse
andHIV/AIDSamongMSMs,HIV/AIDSclearlyintertwineswithsubstanceabuse.Unfortunately,similartoIDUs,itisestimatedthat
only10percentofallMSMswhoabusesubstancesseektherapyatsubstanceusedisordertreatmentcenters.Becauseofthestigmatization
ofMSMs,HIVinfectedMSMsubstanceuserseitherdonotseektreatmentattraditionalsubstanceusedisordertreatmentcenters,orthey
remain"closeted"whentheydoattendtreatment.

Outreach
OutreachstrategiesforHIVpreventionmayreadilytranslatetosubstanceuseinterventions.Inaddition,theretendstobeastigmaagainst
substanceusersinthegaycommunity,andoutreachworkersmustbepreparedtohelpclientsovercomethestigmainordertogetinto
treatment.

Ofconcerninthispopulationisthatanyinjectiondruguse,anduseofinjectedmethamphetamine(MA)inparticular,increasestheriskof
HIVand/orhepatitistransmissionfromneedlesaswellasfromdruginducedbadjudgment,feelingsofinvulnerability,riskybehaviors,
andrepetitiveandprolongedsexualbehavior.AstudyofMAusinggaymeninLosAngelesfoundthat62.5percentofallparticipants
reportedhavinganalsexwithoutacondom,and56.3percentreportedhavingsexwithsomeonewhohadHIV(Froschetal.,1996).For
counselorsandoutreachworkers,riskassessment,includinguseanalysisfocusedonhowsexfitsintotheusepatterns,iscritical.Itis
importantintheassessmentprocesstocapturethesepatterns.

Educationofcounselors,aswellasclients,regardingtheparticulareffectsofthisclassofdrugsisextremelyimportant.Recently,there
hasbeensomebackslidingwithregardtoinjectiondruguseandsexualbehaviorsbecauseoftheperceptionthatthenewAIDSdrugs
meanapositivediagnosisisnolongerautomaticallyadeathsentence.Notonlydoesthismythneedtobecountered,butinformationonthe
effectsoflongtermstimulantusecoulddiminishtheattractivenessofMAenhancedsexualperformance.Sideeffectsoflongtermuse
includediminishedsexualdesireandperformance.Withiceinparticular,clientsshowdecreasedabilitytoachieveorgasm,briefer
erectionperiods,andanincreaseinimpotence.Finally,counseloreducationneedstoensurelackofbiasandsensitivitytothesexual
practicesofgaymen.

Methadone Maintenance Clients


Cocaineandheroinaresometimesusedtogetherinapracticecommonlyknownasspeedballing.Someclientsclaimthatmethadone
lengthensandmellowstheeffectsofcocaine,presumablyattenuatingthenegativereinforcersassociatedwithcocainecrash(Condelliet
al.,1991).Somepatientsalsousealcoholorbenzodiazepinesorbothconcurrentlywithcocaineandherointoreducetheseeffectsofthe
cocainecrash,oftenmarkedbyanxiety,depression,fatigue,andjitteriness.Thus,justasheroinusecanincreasethelikelihoodofcocaine
dependence,cocaineusecanincreasetheriskofheroindependence(Duntemanetal.,1992).

AlthoughmethadoneisveryrarelycombinedwithMA,therearesomeissuesinthispopulationofwhichcounselorsshouldbeaware:
treatmentdifficulties,medicalrisks,cocaineuse,counselortraining,andneedforenhancedservices.

Epidemiology
Stimulantabuseratesamongmethadoneclientsvarybyprogrambutrangefrom40to60percentininnercitypopulations,accordingto
dataonpositivescreensforcocaine.ThesedatasuggestthattheroutestoMAuseareestablished,andfurtherstudymayberequiredto
determinetheextenttowhichtheyareused.Inaddition,datashowaveryhighnumberofsedativeusers,includingusersof
benzodiazepines,amongmethadoneclients.

Individuals With Co-Occurring Mental Disorders


Individualswithcooccurringmentaldisordersmaybedefinedasthosepersonswithcoexistingstimulantuseand/orothersubstanceuse
disordersandanyofthefollowingdisorders:
Majordepression
Dysthymia
Bipolardisorder
Antisocialpersonalitydisorder
Panicdisorder
Agoraphobia
Socialphobia
Posttraumaticstressdisorder(PTSD)
Attentiondeficit/hyperactivitydisorder(AD/HD)
Schizophrenia

ItiscriticaltobeawareofthefactthataDSMIVdiagnosisofamentaldisorderisdifferentfromthemereproductionofsymptoms
(AmericanPsychiatricPress,1994).Forexample,moststimulantuserswillentertreatmentexhibitingsymptomsofdepression.Similarly,
manyMAuserswillexhibitpsychoticsymptomsthatarequitecommoninschizophrenics.However,thesymptomsofdepressionarenot
thesameasthepsychiatricillnessofdepression,norarethepsychoticsymptomsevidenceofschizophrenia.Manyofthesymptom
clusters,commonlyassociatedwithspecificpsychiatricdisorders(e.g.,depression,anxiety,psychosis,bipolarmoodfluctuations,
antisocialbehavior)arefrequentlyseenduringtheuseofstimulantsorduringtheperiodofearlyabstinence.

Infact,manyindividualswillbringtheirpsychiatricdiagnosisintotheirsubstanceusedisordertreatmentevaluation.Manystimulantusers
havesoughtpsychiatriccarefortheirstimulantproblemsbeforeenteringtreatment(manyindividualsapparentlyfeelitispreferableto
haveadiagnosisofdepressionorbipolarillnesstosubstancedependence).Therefore,theywillcontendthattheyhaveapsychiatric
disorderandrequirepsychiatriccare(i.e.,medication,psychotherapy)ratherthansubstanceusedisordertreatment.

Itshouldnotbeassumedthatbecauseanindividualhasreceivedapreviouspsychiatricdiagnosis,orbecauseshehassymptomstypically
associatedwithapsychiatricdisorder,thatsheisnecessarilya"dualdiagnosis"client.Theaccuratediagnosisofpsychiatriccomorbidity
amongstimulantusersrequiresconsiderablediagnosticsophistication.Itisoftennecessarytomakeaprovisionaldiagnosis,whichis
modifiedafteradditionaldataarecollected.Formanycocaineusers,itisoftennecessarytohave1to2weeksofcocaineabstinencefor
MAusers,itisoftenhelpfultohave30daysofabstinencetomakeanaccuratepsychiatricdiagnosis.Anotherimportantelementinthe
diagnosisistoobtainacarefulhistoryregardingthehistoricalrelationshipbetweentheonsetofpsychiatricsymptomsandthesubstance
usehistory.

Dualdiagnosiswilloftenencompassthreeormorecoexistingconditions.Clientswhousestimulantsmayormaynothaveanunderlying
psychiatricdisorder,anditisoftenimpossibletodiscernthesourceofbehaviorssymptomaticofapsychiatricconditionuntiltheclientis
substancefree.Inmanycases,amonth'sabstinencewillberequiredbeforeanaccuratepsychiatricassessmentcanbecompleted.
Althoughtreatmentofclientswithadualdiagnosiscanbecomplex,thispopulationoftenhitsbottomfasterandthereforeenterstreatment
morequickly,andoftenwithmoremotivation,thandoclientswhousesubstanceswithoutthemoreseriousunderlyingproblems.

Specialized Treatment Interventions


ConsensusPanelsuggestionsfortreatmentinterventionsforpersonswithastimulantusedisorderandacoexistingpsychiatricdisorderare
discussedinthesectionsbelow.

Affective disorders

Symptomsofdepressionmayoccuraspartoftheuseoforwithdrawalfromstimulants.Wherepossible,itishelpfultowaittotreat
depressionuntiltheclienthasbegunrecoveryfromasubstanceusedisorder,andtheConsensusPanelrecommendswaitingtouse
medicationtotreatdepressivesymptomsifatallfeasible.However,iftheclientissuicidal,hospitalizationistherecommendedcourseof
action.

Bipolar disorder

Clientswithbipolardisordermaybetreatedintraditionaltreatmentsettingsiftheyarewellcontrolledontheirmedicationsforthe
bipolarcondition.Useofstimulantscaninitiateamanicepisode.Therefore,medicationmanagementisoneofthemostimportantissues
intreatingclientswithbipolardisorder.

Antisocial personality disorder

Thediagnosisofantisocialpersonalitydisorders(ASP)isdirectlyaffectedbysubstanceusebehavior.Forexample,manybehaviors
associatedwithchronicMAusemimicASP,includinglawbreaking,aggressiveness,andpoorimpulsecontrol.BothcocaineuseandASP
areassociatedwithviolence.

ManyclientswithASPareinvolvedwiththecriminaljusticesystem,socoordinationbetweensystems(substanceusedisordertreatment,
mentalhealth,physicalhealth)isimportant.Generally,menaremorelikelythanwomentopresentwithASP,andmentypicallyuse
substancesatahigherrate.Therefore,programsthataregearedtowardmaleclientswithASPandcriminalinvolvementarenecessaryin
asubstanceusedisordertreatmentsystem.

Panic disorder

Cocaineusecaninducepanicdisorders,whichcanactasatriggerforpanicattacksevenafteraclientissubstancefree.Panicdisorders
seemtobecommonforbothcocaineandMAuserslongaftertheyhavediscontinuedusingthedrugandareoftenassociatedwith
depressionssecondarytococainewithdrawal.Healthcareprovidersshouldexerciseextremecareinprescribingbenzodiazepinesforthis
disorder,duetotheirhighaddictionpotential.Cognitivebehavioraltechniquestorecognizeandmanagesymptomsmaybesomeclinically
usefulstrategies.

Posttraumatic stress disorder

Often,womenwhouseiceareatanincreasedriskofPTSDbecauseofsubstancerelatedepisodesofdomesticviolence,sexualassault,
andincest.

Recommendedtreatmentapproachesincludereferringclientstosexualassaultandincestsupportgroupsasquicklyaspossible.Group
counselingshouldbeavailableinawomanonlyformatandshouldincludecoachingonwhattoexpectfromdreams,fears,andsleep
disruptionsasaresultofPTSDandwithdrawalfromice.Informationonpracticaltoolstocombatnightmaressuchasnightlights,herb
teas,relaxationtechniques,aswellasinformationonrelapsetriggers,willprovideclientswithreassuranceandskillstogetthroughthis
period.

CounselorsneedspecialtrainingtoworkwithindividualswithacooccurringsubstanceusedisorderandPTSD.Issuesincluderelapse
triggers,timingofaddressingissuesingroupsessions,andthetoolsandsocialskillswomenneedinordertofacilitateasuccessful
recovery.

AD/HD

TheprevalenceofAD/HDinthegeneralpopulationrangesbetween3and9percentofadults.Inthepopulationofadultswithsubstance
usedisorders,theprevalenceofAD/HDrangesbetween1and5percent.However,onestudyhasfoundthatinthepopulationofpersons
withadultAD/HD40percenthadcooccurringsubstanceusedisorders,generallyinvolvingmarijuanaoralcohol(Biedermanetal.,1993,
1995).ThesesubstanceusedisordersweredetectedwhentheclientsenteredtreatmentforAD/HD.

ItiscriticaltoretrieveaclearlongitudinalhistoryofbothsubstanceuseandsymptomsofAD/HDpriortocompletingadiagnosisofco
occurringdisorder.SideeffectsofcocaineusecanmirrorsomesymptomsofAD/HD,buttheydisappearwhenuseceases.Generally,
personswithadultAD/HDhadthediseasewhentheywerechildren,althoughitmaynothavebeendiagnosedassuch.Itisimportantto
includeanassessmentofchildhoodsymptomswhencompletingtheclient'shistory.ThepresenceofAD/HDsymptomsinchildhood
providesareliabilitymeasureforthepresenceoftheadultdisease.

Schizophrenia

Estimatesoftheprevalenceofsubstanceusedisordersintheschizophrenicpopulationrangefrom30to50percent.Muchofthisuse
stemsfrompeergroupseekingbehaviors.Usingsubstancesisnormal,it'swhattheotherpeopleonthestreetsaredoing,andsubstance
usecangivepersonswithschizophreniathesenseofwellbeingandfittingtheyotherwiselack.

Itisimportanttotreatsubstanceuseinclientswithschizophreniaimmediatelyinordertoallowmedicationforthementalillnesstimeto
takeeffect.Apersonwithschizophreniawhocontinuestousecocainewillbecomefullypsychotic,andthosewhocontinuetouseMA
willdevelopapsychosisindistinguishablefromthatcreatedbyparanoidschizophrenia.

Afterastabilizationperiod,treatmentforbothconditionscanoccursimultaneouslywithslightmodifications.Modifiedgroupcounseling
maybeusedtotreatsubstanceusedisorders.However,groupsmustbesmallerandmorecontrolledthanintraditionalsubstanceuse
disordertreatment,andconfrontationalsettingsshouldbeavoided.Tobeeffective,eachgroupsessionshouldfocusonaparticularskillor
topic.

Medically Ill Clients


Thissectionreferstoclientswhoareundergoingtreatmentforasubstanceusedisorderandwhohaveoneormorecooccurringmedical
disorders.Goodclinicalpracticesuggeststhat,priortoinitiationoftreatmentforasubstanceusedisorder,eachclientshouldbegivena
thoroughphysicalexamination.Followupshouldincludecontactwiththeclientsandotherprovidersandreviewoftreatmentrecordsfrom
them.Inaddition,treatmentprovidersshouldbetrainedinthefollowing:

Howtodetectchangesinmedicalconditions
Howtodifferentiatebehaviorsrelatedtosubstanceusefrombehaviorsrelatedtoadeterioratingmedicalcondition
Howtodecidewhetherornotareferraltoaphysicianisinorder

Finally,itisimportanttonotethatlinkagesbetweensubstanceusedisordertreatmentprovidersandthephysiciansandspecialistswho
treattheclientcanimprovetreatmentoutcomesfortheclient.

Thissectiondiscussessomemedicalconditionsthatrequireparticularattentiononthepartofthesubstanceusedisordertreatment
provider:epidemiology,diabetes,andHIV/AIDS.

Epidemiology
Chapter5ofthisTIPdiscussedsomeofthecommonmedicalillnessesseeninsubstanceusingpopulations.Becausethestimulantusing
populationtendstobeyounger,themedicalconditionsarenotgenerallyassevereasobservedinthepopulationofsubstanceusersasa
whole.Forexample,becausemostpersonswhousestimulantsrangeinagefrom25to35years,theydonotpresentwithconditions
commontomiddleandoldagesuchascoronaryarterydisease.Generally,primarymedicalproblemsaredental,dermatological,ear,
nose,andthroat,otitismedia,nutritional(verythinclientswhoeitherusecocaine,haveAIDS,orboth),asthma,neurologicaldisorders,
seizures,andresidualproblemsfromastroke.Secondaryconditionsincludebloodbornediseases,HIV,hepatitis,andsexuallytransmitted
diseases.

Stimulantusersinparticularpresenthigherratesofthyroidproblems,intheformofpermanenthyperthyroidismorhypothyroidism.This
maybeattributedtoimpureMA,resultinginachemical,tissuespecificreactioninthethyroid,butmoreresearchneedstobeperformed
inthisarea.Foracompletelistofthegeneralmedicalcomplicationsofstimulantuse,pleaserefertoChapter5.

Hepatitis
Personswhousestimulantsareoftenatriskforhepatitis,which,duetotheeaseofglobaltravel,isnolongerrestrictedtoThirdWorld
countries.TheCentersforDiseaseControlandPrevention(CDC)estimatesthat150,000peopleintheUnitedStatesareinfectedeach
yearbyhepatitisAalone.TheCDClistshouseholdorsexualcontact,sharingofinfectedneedles,andrecentinternationaltravelasthe
majorknownriskfactorsfortransmissionofhepatitisA.HepatitisBvirus(HBV)isamorevirulentformofthediseaseandismuch
moreprevalentthanHIV,withanestimated1.2millionAmericanscurrentlychroniccarriersofHBV.HepatitisBmaydevelopintoa
chronicdisease(whichmeanslastingmorethan6months)inupto10percentofthe200,000newlyinfectedpeopleeachyear.Ifleft
untreated,theriskofdevelopingcirrhosis(scarringoftheliver)andlivercancerisincreasedinclientswithchronichepatitisB.
Treatmentprogramsforstimulantusersshouldincludeascreeningforhepatitisineachclient'sinitialassessment.
HIV/AIDS
AnotherimportantinitialscreeningforpersonswithstimulantusedisordersisthatforHIV.ClientsmaybereluctanttoundergoanHIV
testbecausetheyfeartheresults.However,beingdiagnosednegativecanactasapowerfulmotivatorforstimulantuserstocomplywith
treatmentmorefully,oncetheynolongerfearthattheywilldevelopAIDS.Testingnegativecanalsoencourageclientstopractice
preventivemeasuresinotherareasoftheirlives.Testingpositive,althoughdiscouragingtotheclient,isanimportantpartofthescreening
thatthetreatmentproviderneedstobeawareof.OncetheHIVstatusoftheclientisknown,treatmentcanbeplannedthatwillincludea
medicalcomponentinthesubstanceusedisorderrecoveryprogram.

However,somespecialissuesremain.OneofthecriticalaspectsofprovidingsubstanceusedisordertreatmenttopersonswithHIVor
AIDSisthecontinuingeducationthatprovidersneedregardingthechangingandcomplexarrayofmedicationregimensavailabletothis
population.Inaddition,providersshouldknowthatclientswithHIV/AIDS,armedwiththesenewmedicines,areapproachinglife
differently.Nowthattheyknowtheywilllivelonger,theymayreturntousingsubstances.

AnissuewithstimulantuseistheincreasedriskofcontractingHIVthroughthehighrisksexualbehaviorfacilitatedbythedrug.Byand
large,clientshavegrownmoreawareoftheriskoftransmissionfromneedles,althoughthisisanareathatrequiresfurtherstudy.
CocaineusershavemoreopportunitiesforexposuretoHIVthandootherstimulantusersbecausetheyrequiremultipleinjectionsto
maintainahighandthereforemayrunoutofneedlesmorequicklyandbetemptedtoshare.Barteringsexfordrugsisamorelikelyroute
toHIVinfectionthanuncleanneedlesforMAusers,becauseMArequiresfewerinjections.

TreatingclientswithHIV/AIDSisanotherareainwhichprogramlinkagesbecomecriticaltosuccessfultreatment.Itishelpful,where
possible,tohavestaffandnursesskilledineachtypeoftreatmentsituatedtoprovideclientsconvenientaccess.Anecdotaldatafrom
providersindicatethatclientstendtogetlostonthewaytoareferralappointment,andcolocatingproviders,suchasanobstetrician
gynecologistinamethadoneclinic,helpstomitigatethisproblem.Formoreinformationonthistopic,pleaserefertoTreatmentforHIV
InfectedAlcoholandOtherDrugAbusers(TIP15)(CSAT,1995arevisioninpress).

Criminal Justice Clients


Asignificantamountofcrimeiscommittedbysubstanceusers,anditisimportanttocarefullyassessthispopulation.Manypersonsinthe
criminaljusticesystemcommitcrimeswhileinhibitionsarereducedbysubstanceuse,andothersstealinordertobuydrugs.Thesetypes
ofclientsformthetargettreatmentpopulation.Otherpersonsinthecriminaljusticesystemsimplyselldrugsbutdonotusethem,oruse
drugsbutarenotaddictedtotheparticulardrugtheysell.Selfreportdataindicatethat72percentofpersonsinthecriminaljustice
systemaresubstancedependent.Theseclientsareoftenextremelycomplexintermsofcasemanagement:Oneclientmayhave
simultaneousinvolvementinthecriminaljustice,substanceusedisordertreatment,andmentalhealthsystems.Thereislittleresearchon
thespecificissuesfacedbycriminaljusticeclientswithstimulantusedisorders.

Formoreinformationonthistopic,pleaserefertoTIP12,CombiningSubstanceAbuseTreatmentWithIntermediateSanctionsfor
AdultsintheCriminalJusticeSystem(CSAT,1994c)TIP17,PlanningforAlcoholandOtherDrugAbuseTreatmentforAdultsinthe
CriminalJusticeSystem(CSAT,1995c)TIP21,CombiningAlcoholandOtherDrugAbuseTreatmentWithDiversionforJuvenilesin
theJusticeSystem(CSAT,1995e)TIP23,TreatmentDrugCourts:IntegratingSubstanceAbuseTreatmentWithLegalCaseProcessing
(CSAT,1996)andTIP29,ContinuityofOffenderTreatmentforSubstanceUseDisordersFromInstitutiontotheCommunity(CSAT,
1998b).

Racial/Ethnic Considerations
Oneofthemostimportantissuesindevelopingtreatmentoptionsfordifferentracial/ethnicgroupsistomovebeyondculturalsensitivity
andintoculturalcompetence.Culturalcompetenceisnotjustanunderstandingofsuperficialethicdesignationsbutinsteadaknowledgeof
regionalandsocioeconomicpatterns.

Culturalcompetenceiscriticalforworkinginthedrugtreatmentfieldtoday,becauseprovidersneedtobeculturallysensitivewhen
workingwithdiversepopulations.Progressivelyincreasinglevelsofculturalcapacityinclude:

Culturalsensitivity
Culturalcompetence
Culturalproficiency

Culturalsensitivityinvolvesabasicunderstandingandappreciationofsocioculturalfactorsastheserelatetotheclient'streatmentneeds
andthechoiceofrelevanttreatment.Culturalcompetenceinvolvesagreaterdepthofunderstandingoftheclient'sneedswithinthe
client'sculturalcontext.Italsoinvolvesgreaterskillsandexperiencesthatallowworkingwithculturalnuancesaspresentedbytheclient,
andthecapacitytointerpretdeepermeaningsintheclient'sthoughtsandbehaviors.Culturalcompetenceaidsinmakingbettertreatment
decisionsbecauseitisbasedonamoreeffectivematchingoftheclient'sneedswiththerelevanttreatmentoptions.

Outreach
Outreachissueswillbespecifictothetargetedethnicpopulation,buttopicstoconsiderforeachinclude

Locationoftreatmentcentersandcommunitybasedorganizations
Availabilityofdropincenters
Availabilityofnonconfrontationalprograms
Programsthatspendmoretimeintheengagementphasepriortocounseling
Programsthatofferindividualizedapproaches,encouragetheestablishmentofsaferelationships,allowtimefortrusttodevelop,
andassessthelevelofmotivationforchange
Counselorstrainedtohelpclientsidentifytheirownethnicissues
Counselorsmatchedtoclientsbyculturalcompetence(notnecessarilyracial/ethnicbackground)

Manyoftheaboveconsiderationsinvolveslowingdownthecourseoftreatmenttoaccommodateracial/ethnicmores.Ofconcerntothe
ConsensusPanelisthemethodofpaymentforthistypeofcare.Managedcareisreluctanttofundlongtermtreatmentortreatmentsthat
cannotbereducedtobillableunits.

Rural Populations
Accordingto1990censusdata,approximately25percentoftheU.S.populationlivesinruralareas.Colorado,Idaho,Montana,New
Mexico,NorthDakota,Nevada,SouthDakota,Utah,andWyominghavebeenidentifiedas"frontierStates,"withatleasthalfoftheir
countiespossessingsixorfewerpersonspersquaremile.AllofthesearewesternStatesinwhichMAuseishigh.

TheNationalHouseholdSurvey,conductedbytheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA),revealed
thatlargemetropolitanareasandruralareashadsimilarratesforsubstanceuseamongyouths12to17yearsold(SAMHSA,1998).What
differedwasthespecificsubstancesused,nottheprevalenceofsubstanceusage.

StrictregulatorycontrolsonlawfullymanufacturedMAlimititsdiversionfromlicittoillicitchannels.ThebulkofMAcurrentlyonthe
streetshasbeenillegallymanufacturedinclandestinelabs.Ruralareasareathighriskforbeingtargetedbydrugmanufacturersand
dealers.Aruralcommunityofferssecludedareasinwhichtoproduceillegaldrugsandaccesstomajortransportationroutesfor
distributionwithminimalriskofdiscoverybylawenforcement.Smalltownstendtobeonmajorhighwaysandinterstates,which
facilitatestransportationtootherregionsforsaleanddistribution.Thisisariskfactorthatmanyruraland/orfrontiercommunitiesare
unpreparedforbecausetheyoftenlackthetreatmentresourcesorthecommunityinfrastructure,suchaspoliceforcestrainedspecifically
indealingwiththeseissues.Thiscanleadtoswiftandsevereproblemsforillpreparedcommunities.

Prevalence in Rural Areas


ThenumberofMAtreatmentfacilityadmissionsishighestinthewesternStateswheretheynowsurpasscocaineadmissions.Primary
MAadmissionratesarebeginningtoriseinsomesouthernandmidwesternStates.

IntheStateofNevada,(afrontierState),theclientdatasystemfor1997admissionstopubliclyfundedsubstanceusedisordertreatment
centersreportedthatofthoseindividualsseekingtreatmentforsubstanceusedisorders,52percentwereseekingtreatmentforMAuse.

Challenges, Limitations, and Barriers to Treatment Services Faced by Rural Areas


Ruralareasfacethechallengeofprovidingaccesstoservicesforclientswhomaylivehundredsofmilesawayfromthenearest
treatmentprovider.Anentiredaymightbespenttravelingbycartoaserviceprovider,becausemostruralareaslackpublic
transportation.

Ruralareasusuallyhaveafragmentedservicesystemandlimitedresources.Thelackofmedicalandsocialservicesinruralareas
prohibitsanycontinuumofcareorevenreferralforspecializedcare.Inmanyruralcommunitiestherearenotreatmentservices
available.Oftenonlyonesocialserviceproviderisavailableandisgenerallyoverwhelmedbythevariousneedsofthecommunity.Social
serviceagenciesinruralareastendtobemultiserviceagenciesoutofnecessity.

Ruralcommunitiesaregenerallyallocatedminimalfundingfortreatmentbecausefundingisusuallybasedonpopulation,whichresultsin
theprovisionofminimalservices.Therearerarelyanysourceswithinthecommunityfromwhichtoseekadditionalfunding.Thelackof
adequatefundinglimitsstaffing,staffsalaries(whichcontributestoahighstaffturnover),andtheabilitytoprovidesupportservicessuch
aschildcareortransportationintheareaswherethatsupportisneededmost.

Confidentialityisrareinruralsettings.Thereisnoanonymityinasmallruralcommunity.Everyoneknowseveryoneandobserveseach
other'scomingsandgoings.Mostruralcommunities'lackofavailableandappropriateofficespaceleavestreatmentproviderspracticing
inwhateverspacetheycanfindwhichofteninvolveslittleprivacy.

Continuingeducationfortreatmentprovidersisnonexistentinmostruralareas.Consequently,treatmentprovidersoftenlackthemost
currentinformationinthefield.

Strategies To Provide Services In Rural Areas


Thefollowingarevariousstrategiesthatcanhelpprovidetreatmentservicestoruralpopulations:

Providerscanformaconsortiumbetweeneducators,counselors,andlawenforcementofficers.Byforminglinkagesbetween
variousagencies,smallcommunitiescanhaveequalaccesstotreatmentservices.Theconsortiumcanthenuselocalstatisticson
substanceuserelatedmortalityrates,arrestsfordrivingundertheinfluence,schoolsurveydata,crimerates,andsoon,to
evaluatecommunityneeds.Ifdatacannotbecompiledeasilybycommunitymembers,theStatesubstanceabusetreatmentoffice
caneitherprovidethatinformationordirectindividualswheretofindit.
Differentproviderscansharestaffandcrosstrainprofessionalsandparaprofessionals.Ifthewelfareworkerisknowledgeable
aboutaddictions,shemaybealerttosymptomsofsubstanceabuseintheclientwhocomesinforfoodstamps.Conversely,the
addictionscounselorcanidentifyotherneedsandprovidethepropercasemanagement.
Treatmentprogramscanprovidebasictrainingofmedicalpersonnel,communitysocialworkers,teachers,schoolcounselors,
lawenforcementofficers,judges,andchildcareproviderswithinacommunity.Thiscangoalongwaytowardstretching
resourcesandraisingcommunityawarenessoftheissues.
Programscanprovidesafeandsubstancefreelivingarrangementsforclientswhileintreatmentawayfromtheirhome
community.Fundsforthiscanbeespeciallydesignated,solicitedthroughrecoverycommunitynetworking,orobtainedthrough
donations.
Programscanprovidetreatmentservicesthatareflexibleinscopeandstructure.Forexample,anintensiveoutpatientprogram
mightoffera6hoursessiononSaturdayandSundayinsteadofthemoreusualweekdaysessions.Treatmentproviderscanalso
practiceflexibilitybyassigninghomework,arrangingphonecheckin,havingdrugtestingdonebyoutlyingclinics,usingonline
communication,andholdingweekendworkshopsorretreatsinsteadoftraditionalweeklysessions.
Nontraditionaloutreachsitescanbeusedfortreatmentservices.Atreatmentfacilityinasmallruralcommunitymaynotbe
realistic,butitmaybefeasibletoemployaparttimepersoninasatelliteofficewhotravelstodifferentsatellitesitestoprovide
outpatientservices.ManyruralStateshavemobileruralhealthcareanetworkofvansthattakeprimarycaremedicalservices
toruralandisolatedcommunities.Substanceusedisordertreatmentcouldbecomeanadditionalserviceprovidedinthismanner.
Likethemobileapproach,someruralStatesalsocontracttreatmentcounselorstotravelfromoneruralsitetoanotherduringthe
courseofaweekandwhoworkoutofothercommunityserviceproviders'offices.Althoughmanycommunitieslacksufficient
officespaceinwhichtosetupatreatmentcenter,nearlyeverycommunityhasaschoolandachurchthatcanserve.Thereis
generallyahealthcareorgovernmentserviceofficewithinareasonabledistancethatmayprovidesomespacefortreatment
servicesonalimitedbasis.
ProgramscanworktodevelopoutreacheffortswithsponsorshipfromStateagencies.Sucheffortscanhelpfosterastrongself
helpnetworkinruralcommunities.Everycommunityhas"recovered"and"recoveringpeople."However,theseindividualsoften
haveneverconsideredorganizingthemselvesintoamutualsupportnetwork.MostchaptersoforganizationssuchasAlcoholics
Anonymous,NarcoticsAnonymous,andRationalRecoveryhavememberswhowouldgladlyextendtheirhelpandexperiencein
developingsuchanetwork.
Continuingeducationvideotapesareapossibleresourceforruraltreatmentproviders.Statesubstanceabuseofficesandurban
treatmentproviderscanprovidevideotapesforthosewhocannotattendoraffordtheongoingtrainingthatisavailableinurban
areas.

Women's Issues
Treatingstimulantusedisordersinwomencaninvolveahostofcomplexissues(includingpregnancy,children,domesticabuse,and
socioeconomicproblems)thatcanimpactdiagnosisandtreatmentofstimulantusedisorders.However,althoughwomen'suseof
stimulantshasnotbeenwellstudied,onerecentstudydoespointtoagenderdifferenceinwomen'sresponsetococaine(Lukasetal.,
1996).Inaddition,inrecentstudiesofMAuse,thepercentageoffemaleMAusersappearshigherthanwithsamplesofcocaineorheroin
users(Rawsonetal.,1998a).

Epidemiology
AlthoughMAuseistraditionallyassociatedwithmales,growingnumbersofwomenareusingthisclassofdrug,forreasonsrangingfrom
adesiretoloseweighttothewishtobea"superwoman"whomustselfmedicatetogetthroughanoverextendedday.Dataonwomen
whoweresexuallyabusedaschildrensuggesttheyusecocaineasadultsinorderto"feelbetter."

Outreach
Thereareanumberofentrypointsinthesystemforwomenwhomightnotpresentdirectlyfortreatment,including

Pediatricians(motherswilltakechildrentothedoctorevenwhentheywillnotgofortheirownproblems)
Childprotectiveagencies
Socialserviceagencies
Primarycareproviders
Criminaljusticesystem

Twotypesofbarriersmustoftenbeaddressedconcerningoutreachtowomenwhousesubstances,includingstimulants.First,internal
barrierstoseekingtreatmentforsubstanceusedisordersthatincludeguilt,depression,fearofchildrenbeingtakenaway,andfearof
partnerswhoareusingordealingdrugsmustbeidentifiedandmitigated.Second,externalbarrierstobeexaminedincludelackof
accessibilitytotreatmentprograms,needforchildcare,orlackofcommunitybasedprogramsthatpreventwomenfromseeking
treatment.Often,reducingjustonebarrierisenoughtobringawomanintotreatment.Forexample,treatmentprogramsthatprovidechild
caremayhavehigherparticipationlevelsthanthosethatdonot.

Treatmentprogramsmustfocusonthephysicalhealthofthewomanenteringtreatment.Anecdotaldatasuggestthatwomenexperience
morerapidphysicaldeteriorationthanmenfromMAandcocaineuse,butthereisnosolidresearchbasetosupportthisobservation.
Generally,bythetimewomengetintotreatmenttheyaresickerthantheirmalecounterparts.Inaddition,womenwhoarenotinthe
workplacemayhaveusedthedrugforalongerperiodoftimewithoutdetectionthantheirworkingcounterpartsandwillbeinworse
shapewhentheydoentertreatment.

Treatmentprogramsmustalsoconsiderthetypeofstimulantused.Ice,becauseitisadrugthatisoftenusedinfamilyorcommunity
settings,exacerbatesallofthewomen'sissuesdescribedinthissection.

Treatmentforwomenshouldinvolveaholisticapproach,includingconsiderationofthefollowing:

Relationshipswithfamily(aftersocialfunctioning,issuesofhomelessness,socialisolation)
Treatmentneedsofchildren
Domesticviolence
Parenting
Lifeskills
Educationandvocationaltraining
Economicselfsufficiency
Reproductivehealthissues
Educationaboutlongtermaffectsofusingstimulants
Mentalhealth
Dependencyissues
Selfesteem
Independentlivingskills
Nutrition
Transportation
Ethnicandculturalissues
Daycareandgroupcounselingforchildren
Genderspecificgroups/femalegroupleaders
Longtermeffectsofstimulantsonreproductivehealth

OnerelapseissuetoconsiderforfemaleclientsisthenegativeimpactoflongtermMAuseonsexualperformancethedrugmaycause
womentolosesexualdesireandtheabilitytoachieveorgasm.However,theymayalsoresorttoMAorcocaineuse,ifpressuredforsex,
inordertogetthroughtheexperience.Inaddition,womenwhoreturntothecommunitytolive,butwhoarelivinginadependent
relationship,mayneedtotradesexforfoodandshelter.Thispressureforsexcanleadtoaresumptionofsubstanceuse.

Intensiveoutpatientprograms,whichatfirstglancemayappeartobemoreaccessibletowomenwithchildren,infactpresenttheirown
barriers.Programsthatrequirefrequentonsitevisitsbutdonotprovidechildcareonsitewillnotenhancecompliancewiththetreatment
regime.

Adolescents
Adolescentscanpresentmanyissuesofconcernbesidestheirstimulantuse.Thepathtoabuseanddependenceforthisgroupmaystart
becauseofgeneralsubstanceandalcoholexperimentation,negativepeergrouporgangexposure,attemptstoselfmedicatefor
undiagnosedmentalhealthconditions,poorselfimage(e.g.,thedesiretoloseweight),theneedtofabricateconfidencetofacilitate
criminalactivities,oranycombinationoftheseandotherissuesconfrontingadolescents.Othercontributingissuesmayincludeanxiety,
depression,loneliness,copingwithpastsexualorphysicalvictimization,homelessness,andteenpregnancy.

Theadolescentpopulationiscomprisedofthreesubgroups:

Sixththroughninthgraders(advancedchildren)
Tenthgradersthroughhighschoolseniors
Adolescentsolderthanhighschoolage

Acommontreatmentprincipleacrossallsubgroupsisthat,toadolescents,theconceptofdeathissoremoteastorenderscaretactics
uselessinpursinglifelongsobriety.However,thispopulationoffershopetotreatmentprovidersbecauseadolescentsarenotyet
entrenchedintheirillness,andifsubstancescanberemovedfromtheirlives,theycanmoveonandlearnwiththerestoftheirpeer
group.Althoughtherearemanyproblemsinherentintreatingthispopulation,therewardsofsuccesscanbethatmuchgreater.

Epidemiology
AlthoughnationalstudiesatthistimedonotshowevidenceofhighusageratesofMAorcocaine,thesesubstanceswarrantattentionfor
atleasttworeasons.First,adolescentstendtobemultiplesubstanceusers,soanincreaseinuseratesreportedforothersubstancesand
stimulantscanbesomewhatindicativeoftrendsinuseofMA,andsecond,adolescentstendtousesubstancesthatareconvenientto
obtainthereforeratesofusearelikelytobehigherinareaswithampleavailability.

Nationally,the1996MonitoringtheFutureStudyrevealedanincreaseinopiateandcocaineuseamong8th,10th,and12thgraders,and
teensinparticulardoubledopiateuse(NIDA,1998b).Amphetaminesarenothighonthelistofdrugs,with2to3percentofadolescent
respondentsreportinguseduringtheperiodsurveyed.

Intermsofregionalusebyadolescents,problemareasincludetheWestCoast,Midwest,andHawaii.InCalifornia,ratesofMAuse
amongadolescentsarehigherthanmarijuanause.InHawaii,datafromAdolescentDrugAbuseDiagnosis(ADAD)(treatmentprograms
thatreceiveStatefunding)showthatyoungerpeople(11to12yearsold)arecomingintotreatmentforiceuse,indicatinganevenearlier
initiationofgatewaydrugsleadingtoice.InArizona,althoughtherearenodataontheprevalenceofMAuseamongadolescents,the
proliferationoflabsinboththeinnercityandallovertheregion,includinghomebasedlabs,suggestshigheravailabilityandtherefore
higheruseamongyouthinthisState.

Culturalandsocioeconomicfactorsmayalsopredictuseintheadolescentpopulation.InHawaii,usepatternsamongHawaiianand
Filipinoyoutharerelatedtothehigherusepatternsoftheirculturalgroupsasawhole.Bycontrast,MAuseisnotyetabigissueamong
NativeAmericanadolescents.MAusebyyouthishigherinlowermiddleclassandworkingclassneighborhoods,butadolescentsfromall
socioeconomicclassesuseMA.

Outreach
Outreachtotheadolescentpopulationmustfocusnotonlyonidentifyinghighriskyouthbutmustalsoonidentifyingthemosteffective
methodstoreachthem.Highriskyouthwilloftenhavelowmotivation,dropoutofhighschool,andshowearlyinvolvementinlowlevel
criminalactivity.Oftentheyhaveanumberofhardtotreatpsychiatricissues,suchasconductdisorder,depression,andAD/HD.

Outreachworkersshouldgettotheseyouthsasearlyaspossible.Counselors,teachers,schooladministrators,andotherswhoworkwith
youngadolescentsneedtrainingtoidentifybehaviorsthat,ifleftunaddressed,cancontributetolaterabuseofsubstances,including
stimulants.Generally,themoreproblemsobservedinanadolescent,themoreshewillbeatriskforsubstanceandstimulantabuseand
dependence.

Althoughdataarenotstimulantspecific,itisusefulforpersonswhoworkwithadolescentstoknowthatveryoftenthereisapsychiatric
disorderthatprecedesthesubstanceusedisorder.Itisimportanttotreatthepsychiatricproblemsinordertopreventselfmedication.In
addition,thisgroupofadolescentstendstobeimpulsive,whichputsthemathigherriskforusingsubstances.Adolescentswithdepression
andconductdisordersaremorelikelytogetinvolvedinsubstanceusethanaretheircounterpartswhoarenotdealingwithmentalhealth
issues.

Becausethepublicsubstanceusedisordertreatmentsystemisoftenadultdriven,itishardtoknowwheretoreferadolescentsfor
screeningandassessment.Oftentheyshowupinthejuvenilejusticesystem.Whenadolescentsarereferredforadisciplineproblem,itis
importanttoscreenforcoexistingorunderlyingmentalhealthandsubstanceusedisorders.Anumberofgoodscreeningandassessment
toolsexistforthispurposeforalistofthem,pleaserefertotheupcomingrevisedTIP,ScreeningandAssessingAdolescentsfor
SubstanceUseDisorders.Adultswhocanserveasreferralsourcesforadolescentsubstanceusersincludepediatricians,teachers,school
nurses,andschoolpsychologists.Thismixofprofessionalsisimportantinordertocastawidenetfordetectingadolescentstimulantuse
disorders.

Acautionarynoteforcounselorsnewtothispopulationadolescentsoftenexperimentwithsubstancesandotherrisktakingbehaviors
withoutdevelopingdependence.Therefore,itisamistaketoautomaticallylabelexperimentalsubstanceusebehaviorasaproblemor
dependence.Withthispopulationinparticular,itisimportantnottooveridentifyorlabeladolescentsassubstanceabusers.(More
informationonthistopicwillbeavailableintherevisedTIP,ScreeningandAssessingAdolescentsforSubstanceUseDisorders[CSAT,
1999a].)

Outreachalsoincludespreventionandearlyinterventionefforts.Althoughpreventioneffortsshouldbeginearlier,middleschoolchildren,
11to12yearsold,formanidealtargetforcomprehensivepreventionprograms.Oneexampleincludeslifeskillstrainingprogramsfor
truantyouths(ahighriskgroupwhetherornottheyareusingsubstances).Preventioneffortsthattakeintoconsiderationtheinfluencesof
cultureandfamilyareimportanttoconsider.InHawaii,thepolicedepartmentrunsapreventionprogramforHawaiianyouthsthatis
groundedinthebaseofthelocalculture.

Treatmentsettingsandapproachesforadolescentsinclude

Schoolbasedclinics
Traditionaloutpatientservices
Longtermresidential
Separateschools
Developmentalmodels
Multisystemictherapy
Experimentaltherapeuticcamps
Experimentalwildernessbasedprograms

Programsforadolescentsshouldfocusoncessationofuseaswellasdevelopingthelifeandeducationalskillsthatclientshavemissed
whileusingsubstances.Adolescentsneedmoreintensityinprogramming,suchaspartialhospitalization,orattendingtreatmentafter
school5daysperweek.Itisgenerallybettertoavoidmixingadultsandyouths.

Programsforadolescentsshouldinvolvethefamily,evenwhentreatmenttakesplaceoutsidethehome.Assessmentshoulddetermine
whetherornotthefamilyitselfissubstancefree.Itisalsoimportantthatassessmentandtreatmentprogramsforadolescentsbe
developmentallybased.

Other Considerations
Theadolescentpopulationdemandsheightenedattentionbecauseoftheimpactofstimulantandothersubstanceuseonthisimportant
developmentalbridgeintoadulthood.Stimulantusecanimpedephysical,emotional,andmentaldevelopment.

Adolescentswhouseiceoftenmovequicklyintopsychosis.Thisleadstoaproblemwithdifferentialdiagnosisincasesofpotential
schizophrenia.Withiceuse,itcanbedifficulttodeterminewhetherpsychosisistheresultofschizophreniaorwhetheritwasinducedby
MAuse.

Stimulantuse,especiallyofice,maybeacauseofanearlyonsetofanorexia.Adolescentsoftenabusestimulantsbothtoloseweightand
tocopewithsexualinhibitions.DramaticweightlossinthispopulationisawarningsignforMAuse.However,physicalhealthissues,
otherthananorexiaanddentalproblems,arenotasprevalentintheadolescentpopulationastheyareinthepopulationofadultswhouse
stimulants.

Teenagepregnancyisanotherconcernbecauseoftheassociationofsubstanceuseandearlysexualactivity,compoundedbyimpaired
judgmentregardingbirthcontrolandpreventionofsexuallytransmitteddiseases.

Afinalnoteontheadolescentpopulationconcernsthelackofcommunityresourcesgenerallyavailabletothisgroup.Communitybased
organizationsmustbetapped,especiallyforadolescentsfromminoritygroups.Preventionofsubstanceusedisordersshouldbeapartof
thecurriculumforprofessionalgroupsandcontinuingeducationforanycommunitymemberwhoworkswiththeadolescentpopulation.
(Moreinformationonthistopicwillbeavailableintheupcoming,revisedTIP,TreatmentofAdolescentsWithSubstanceUseDisorders
[CSAT,1999b]).

Publication Details

Copyright
Copyright Notice

Publisher
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)

NLM Citation

Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);
1999. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 6Treatment Issues for Special Groups and Settings.