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Chapter 6 of TAP 11: Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination

Chapter 6–Special Populations

At one time the United States was called a "melting pot," as citizens were molded and adapted to the "American way of life." However, more recently cultural pluralism and diversity are concepts being stressed to promote the coexistence of various cultural groups, all of which may simultaneously maintain some of their distinctive characteristics. Despite such beliefs, there are still conflicts between ethnic and cultural groups, and there is disequilibrium in the power, prestige, and resources available to different groups. These have a tremendous impact on disadvantaged persons who also may be alcohol- and/or drug-involved. It is difficult to separate socioeconomic, ethnic, gender, and other variables that influence some members of these populations. They often experience multiple jeopardies, including minority status, poverty, physical and mental challenges, age, life-styles, and other factors.

Persons who are disadvantaged and disenfranchised have been called "hidden populations" (Lambert & Wiebel, 1990, p. 1). They include groups such as the homeless, chronically mentally ill, high school dropouts, criminal and juvenile offenders, prostitutes, gang members, runaways, and others. Although most people are aware of these citizens, often, less personal and research knowledge is available about them. They frequently are omitted from nationally representative surveys because they are not living in typical homes, are not attending school, or do not want to cooperate with interviews. However, many members of these groups are at greater risk of alcohol and drug abuse, and related diseases, than the general population. Thus, those who may be in the greatest need of treatment have been studied the least (Lambert & Wiebel, 1990).

Despite civil and human rights efforts, the United States remains a country in which members of ethnic minority and other disadvantaged groups are often subject to prejudicial treatment. Some of the life experiences that are different for these various people include language, religion, family relationships, and community norms. Minority groups and other special populations are disproportionately represented among the economically disadvantaged. They are more likely to live in urban centers that have higher crime rates, poorer schools, substandard housing, and few employment opportunities. Because of these disadvantages, many of these group members have required social and financial assistance. Often the bureaucratic structure required to administer these programs results in processes that can be demeaning and uncaring and can foster dependency. This, and past injustices, may result in some persons having difficulty accepting and cooperating with representatives of a different culture (Sweet, 1989).

Difference in language, whether a foreign language or an English dialect, can set apart ethnic populations from the mainstream culture and create communication difficulties (Sweet, 1989). These obstacles increase stress and interfere with psychosocial functioning. Educational opportunities also have not always been equitable with all population groups. Thus, in some instances, services are needed to overcome previous deficiencies as well as to intervene with problems of chemical addiction and dependence.

Despite many struggles, ethnic group members, and other special populations, often display remark-able strengths. In some instances, there are powerful religious beliefs that help sustain members through trying experiences. Family relationships and values may be different, and extended family members and non-related individuals may form supportive bonds that are not typical of Anglo-American groups (Sweet, 1989).

Social attitudes toward users of alcohol and drugs affect concepts and practices of diagnosis and treatment. As the acceptability of alcohol and drug use shifts from one social class to another, attitudes change toward both the substances and the users. For example, before World War II marijuana use was confined to the very wealthy, the underworld classes, and the entertainment profession. After the war, it was increasingly associated with urban ghetto populations who were also noted for use of heroin and cocaine. It was considered very harmful when used predominantly by this population. However, as it became widely used by middle class Americans during the 1960s and 1970s, it was perceived as relatively less harmful and more socially acceptable. Only in recent years has the concern for marijuana use, especially among adolescents, re-emerged (Institute of Medicine 1990; Roffman & George, 1988; Weiss & Millman, 1991).

Individuals, both patients and services providers, are shaped by their social milieu, background, education, and many other factors. They approach a treatment setting and therapeutic experience with varied behaviors and attitudes toward persons who are different from them. Georgetown University (1989) developed information describing a continuum of cultural competence which characterizes various possible responses to persons from cultures other than one's own. These include:

• Cultural destructiveness: These are attitudes, policies, and practices that are destructive to other cultures and their members.
• Cultural incapacity: Systems or agencies lack the capacity to help, but they are not intention-ally destructive to another culture.
• Cultural blindness: Agencies and professionals attempt to treat all people as though they are alike. One's color or culture does not make any difference; services are so culturally neutral that they are not relevant to most of the participants.
• Cultural pre-competence: At this stage, individuals or agencies realize they have weaknesses in their cultural competence and attempt to improve. There is a risk that minimal movement or token changes may be accepted as sufficient.
• Cultural competence: At this level, others are accepted and respected for their differences. One continually strives to expand cultural knowledge through consultation with people of different cultural groups. In program settings, staff who are committed to their particular culture are hired; staff are supported and assisted to become comfortable working in cross-cultural situations; and there is a commitment to policies that enhance different clients and services.
• Cultural proficiency: Different cultures are held in high esteem. Program staff conduct research and publish findings. New therapeutic approaches appropriate for particular cultures are developed. Specialists in cultural competency practice may be hired. Agencies and staff advocate for culturally competent practice and work to improve relationships among cultures throughout the system and society.

There are several special groups of patients with unique characteristics and needs to consider when attempting to match them with the most appropriate treatment options. In some cases, there may be treatment programs exclusively focused on the needs of a particular group of patients, such as women or adolescents. In other cases there may be more subtle program differences, such as staffing patterns or facilities, that make one service preferable to another for certain groups of patients.

Ethnic and racial minorities, as well as many other special popula-tions, encounter significant barriers to obtaining treatment for alcohol and other drug problems. A few of the most prevalent ones include (Office for Substance Abuse Prevention [OSAP], 1990a):

• Funding: Many lack insurance or personal funds to pay for treatment. For inpatient programs, those who are employed face the loss of income for themselves or their family during treatment.
• Availability: Affordable programs often have long waiting lists.
• Child care: Persons with custodial care of young children need assistance for their care during treatment. Many fear the loss of custody of their children if they seek inpatient treatment.
• Cultural barriers: This includes the lack of sensitivity to issues of special populations on the part of some treatment professionals from the mainstream culture.

In this chapter, summary information will be provided about several population groups of special concern in the treatment of substance abuse. Where possible, information related to the incidence of chemical dependency and treat-ment considerations are provided. Other factors also will be discussed.

Medically Ill Populations

The transmission or development of some diseases can be directly linked to the use of alcohol and other drugs. In some cases chemical substances that often are abused are used for medical treatment of emotional and physical illnesses. Other persons with chronic debilitating and painful illnesses or disabilities sometimes resort to alcohol and other drugs for self-medication.

Infectious Diseases

Acquired Immune Deficiency Syndrome (AIDS) has accentuated the role of drug use in the transmission of infectious diseases. The human immunodeficiency virus (HIV) attacks the body's immune system and allows diseases to progress that would not cause illness for a person with a healthy immune system. HIV is spread through exchanges of body fluids in three ways:

• sexual activity;
• blood contact; and
• from a mother to her infant in utero, during delivery or through breast milk.

Although blood contact has included transfusions and blood products in the past, the United States' blood supply is now tested and treated to eliminate virtually all these methods of transmission. However, injection drug use accounts for a growing number of AIDS cases. Injection drug users, and their sexual partners, are the second largest group of persons who have contracted AIDS. They accounted for more than 33 percent of all AIDS cases reported to the Centers for Disease Control and Prevention (CDCP) through September 1993. Injection drug use, or sex with an injecting drug user, was a risk factor for 29 percent of AIDS cases among adult and adolescent males.

Drug use plays a more significant role in adult and adolescent female AIDS cases. Forty-nine percent of female AIDS cases resulted from injection drug use by women. An additional 20 percent of cases were attributed to sex with infected partners who use injection drugs. Thus, 69 percent of female AIDS cases are related to drug use. In addition, 56 percent of children with AIDS (under the age of 13) had mothers who injected drugs or whose sexual partners were injection drug users (CDCP, 1993).

Official statistics of AIDS cases include only those whose disease has progressed to the point that they have symptoms of certain opportunistic diseases or cancers. Thus, those who may be infected with HIV but whose symptoms are not pronounced are not included in the numbers reported by the CDCP. Predicted trends in AIDS cases indicated a probable growth in the proportion of cases attributable to drug use. Drug-involved persons often do not have access to medical attention or may choose not to use such care. It is also likely that the number of cases of drug-related HIV disease is under-reported.

When syringes are used for injecting drugs, a small amount of blood is drawn into the needle. This remains in the equipment after the drug is injected. Frequently, injection drug users share injection paraphernalia. Sometimes this is done because they do not have money to purchase new needles. In some cases, it is illegal to purchase syringes without a medical prescription. Sharing "works" also is considered a form of social bonding among some drug users. Injectable drugs are sometimes available in incarceration facilities, but injection equipment is scarce. Thus, needle sharing is practiced among injection drug users in prison when they can get drugs. When equipment is shared, there is an opportunity for small amounts of blood from an infected person remaining in a syringe to be injected into the person using the needle next.

Heroin is the most commonly injected drug; however, other drugs, including cocaine, methamphetamine, and anabolic steroids, sometimes are injected. Besides the injection of drugs, alcohol and drug use also may contribute to the spread of HIV disease because substances may inhibit judgment, resulting in unsafe sexual activities and drug use practices.

The incidence of tuberculosis, another infectious disease that is associated with both substance abuse and HIV infection, has increased markedly since the mid-1980s. Tuberculosis is transmitted when droplets containing Mycobacterium tuberculosis are expelled by an infected individual (i.e., through coughing) and are inhaled by another person. In healthy in-dividuals the disease may be inactive, although the person may react positively to a test for the disease. However, with the immune deficiency associated with HIV disease, the disease may be reactivated and become much more serious because of the compromised immune system (Novick, 1992).

Homelessness, malnutrition, alcoholism, and substance abuse also are associated with increased rates of tuberculosis. A combination of factors is responsible for the epidemic among these populations, including (Novick, 1992):

• crowded and unhealthy living conditions in which the disease agent can easily be transmitted from infected to uninfected persons;
• poor general health that com-promises the immune system; and
• lack of compliance with treat-ment regimens for the disease.

A new strain of tuberculosis has recently been detected which is resistant to the medications formerly used successfully to treat the disease. This strain is making treatment of the disease and prevention of transmission to uninfected populations much more difficult.

Poor nutrition, poor general health, stress, and lack of medical care are common conditions among substance abusers. These factors may compromise the immune system, making chemically dependent persons more susceptible to Hepatitis B, sexually transmitted diseases, and other infectious illnesses, in addition to HIV and tuberculosis. More information will be provided in Chapter 7, Substance Abuse-Related Infectious Diseases.

Persons With Mental Disorders

Mentally Ill Populations

Persons who have coexisting psychopathology and substance abuse or dependence are sometimes termed dually diagnosed. Treatment of these individuals is complex because of the multiple potential combinations of the two types of disorders and the possible interactions between the two problems (Beeder & Millman, 1992; Walker, 1992a).

Estimates of the prevalence of individuals with both psychiatric and substance abuse disorders vary. Studies have found that more than half of people who abuse drugs (other than alcohol) have at least one coexisting mental illness. Slightly over one-third of alcohol abusers have at least one mental disorder. Approximately 29 percent of persons with diagnosed mental illness, on the other hand, have a lifetime history of either drug abuse or drug dependence. Among those in substance abuse treatment programs, the rate of overlapping disorders is roughly 50 to 65 percent. This is significantly higher than rates found in the general population (Beeder & Millman, 1992; Rovner, nd).

Several characteristics of individuals with both substance abuse and personality disorders include the following (Walker, 1992a):

• inflexible, maladaptive responses to stressful circumstances;
• significant impairments in loving, working, and relating;
• impulsivity;
• inability to accommodate other people's needs;
• boundary problems, such as getting others to solve their problems; and
• a history of pervasive anger and resentment.

Often those with both substance abuse and mental disorders lack basic resources, including income, food, and housing. They also frequently suffer from a high incidence of untreated health problems, such as dental conditions, hypertension, diabetes, and tuberculosis. In treatment, the dually diagnosed require a large amount of services and the effects of their disorders can be very frustrating to their care-givers (Buckley & Bigelow, 1992).

Persons with attention deficit disorders or minimal brain dysfunction usually are diagnosed as children and continue to have some level of brain dysfunction as they grow up. It has been found that they often use illicit drugs and alcohol for self-medication to alleviate their symptoms (Beeder & Millman, 1992).

The highest rates of dually diagnosed individuals occur in prison populations. The rate among prison populations is roughly four times that found in the general population (Rovner, nd). An estimated 80 percent of the prison population can be diagnosed with psychiatric as well as substance abuse disorders. This represents a dramatic rise in the number of mentally ill offenders in prison and may be attributed to both systems and individual characteristics, including (Chiles, Von Cleve, Jemelka & Trupin, 1990; Jemelka, Trupin & Chiles, 1989; Pepper & Massaro, 1992):

• a decline in the number of psychiatric hospital beds available;
• decreased community mental health care and other support;
• rigid criteria for civil commitment;
• the concomitant use of illicit drugs by persons with mental disorders;
• failure of individuals to continue in treatment; and
• sometimes violent behavior on the part of dually diagnosed individuals.

Dually diagnosed persons are particularly vulnerable to arrest because few community placements are available for them. They tend to fail more frequently in treatment and present more problems than other patient groups (Abram & Teplin, 1991). They also have higher rates of violence, murder, and suicide (Albert, 1990).

In responding to the treatment needs of dually diagnosed patients, whether they are in the community or in the prison population, there are several program characteristics that are recommended, including the following (Abram & Teplin, 1991; Pepper & Massaro, 1992; Walker, 1992b):

• Crisis intervention services are needed to provide detoxification and psychiatric stabilization.
• Identification of dually diagnosed persons is critical. Among those in prison populations, diversion or referral to the mental health system is recommended. This may require improved linkages between criminal justice agencies and community mental health and substance abuse treatment programs.
• A network of community treatment agencies to address the needs of the dually diagnosed is needed. Extensive case management services are key for effective programs. A vast number of service elements needed by each patient must be integrated.
• Combined treatment for both disorders is considered essential. Treating one disorder without attending to the other is likely to be unsuccessful.
• A comprehensive approach to treatment is required, including services to meet basic needs of housing, education, vocational rehabilitation, and vocational opportunities. People also need help with family relationship issues.
• Rehabilitation techniques that address both thought processes and behavioral problems are needed because of the high incidence of minimal brain damage and other neuropsychological impairments.
• Long-term residential treatment in a therapeutic community is effective for some dually diagnosed individuals.
• Relapse prevention programming is vital.
• Continuing care after inpatient treatment and community supervision for those released from incarceration facilities is vital for helping persons maintain recovery.

Dually diagnosed individuals require special attention to their treatment needs. Many experience multiple perils in addition to psychiatric disorders and substance abuse, including HIV and other diseases, homelessness, and increased likelihood of involvement with the criminal justice system. Coordination and collaboration among service systems and decision makers is especially important to meet the complex needs of these patients. To be effective, their treatment must be comprehensive and long-term. However, when recovery is achieved and maintained through effective relapse prevention programming, it is more cost-effective than continued incarceration.

Developmentally Disabled Persons

Developmentally disabled persons have limited abilities to process information, think, and reason because of mental or physical impairments that occur during their developmental years (before age 22). The disabilities result in limitations in three or more areas of life activity, such as (Resource Center on Substance Abuse Prevention and Disability, nd):

• self-care;
• receptive and expressive language;
• self-direction;
• learning
• mobility;
• capacity for independent living; and
• economic self-sufficiency.

Persons with developmental disabilities are capable of learning, but it takes longer and must be more concrete (Glow, 1989).

Socially, developmentally disabled persons often are isolated without close friends and support systems. They tend to be manipulated easily and have difficulty learning from previous experiences. If they use alcohol or other drugs, it is likely to be for the same reasons as other persons do–to socialize, to overcome loneliness, to be accepted, and perhaps to self-medicate for feelings of anxiety or depression. The extent of substance abuse among this population is not well-documented (Glow, 1989). Limited mental abilities also sometimes contribute to poor judgment by developmentally disabled persons. In some cases, others take advantage of their naiveté. At times, this leads to involvement in criminal activities and results in their entry in the criminal justice system.

For developmentally disabled persons with a substance abuse problem, appropriate treatment matching may be challenging because of their difficulty in understanding and processing information. Twelve-Step programs require verbal skills and motivation that may be lacking for some persons. Emotions Anonymous is a self-help program for developmentally disabled persons. Modeled on Alcoholics Anonymous, it also incorporates educational and relaxation techniques. Group problem solving, individual goal setting, and social reinforcement are included in the program (Glow, 1989). More research is needed about this special population group. The extent of substance abuse problems and the most appropriate treatment approaches need further exploration. Treatment providers and decision makers need to collaborate especially closely to consider the needs of this group of persons who may not be able to advocate effectively for themselves.

Ethnic and Racial Minority Populations

Various racial and ethnic groups have different patterns of drug abuse. Black and Hispanic substance abusers tend to use heroin and cocaine more than white addicts; whites tend to abuse a greater variety of substances. The results of some studies have led to the hypothesis that whites tend to use drugs more as a result of emotional problems or deviance than do minority group members (Nurco, Hanlon & Kinlock, 1990).

African Americans, Hispanics and Native Americans are over-represented in the correctional system. Among a sample of inmates in the Bureau of Prisons facilities reported in 1991, the following rates of substance abuse problem were found for various groups:

Native Americans Hispanics Blacks Whites Asians

78.9% 60.2% 54.3% 49.3% 11.1%

(Murray, 1991).

Native Americans

The Native American population consists of approximately 1.4 million persons, including American Indians and Alaskan Aleuts and Eskimos (Hill, 1989). Native Americans are no more homogeneous than Hispanics or Asian Americans. As a special population group, Native Americans are diverse, incorporating an array of tribal and cultural groups with differing values and customs. There is also considerable variation in the settings in which Native Americans live. Some live in urban areas while others reside on somewhat isolated reservations. Some studies include representative groups of all Native Americans, while others focus solely on American Indians, a specific tribe, or a particular locality. These factors influence the rates and types of alcohol and drug addiction found among Native Americans. Treatment approaches must be sensitive to the particular cultural heritage of persons entering programs.

There is a significant problem of substance abuse among Native Americans in the United States. Both male and female Indian youth use virtually every type of drug with greater frequency than non-Indian youth, including alcohol, marijuana, and inhalants. The age at first involvement with alcohol is younger for Indian youths and the frequency and amount of drinking are greater. Well established during adolescence, these trends continue into young adulthood. One study found a higher level of drug involvement among American Indian college students than all other student groups (OSAP, 1990c).

While alcohol and marijuana use are very common among Native American youth, inhalant use is almost twice as high as among all other youth ages 12 to 17. Use of inhalants peaks during the early and middle teens and then tapers off in later years as the availability of marijuana, alcohol, and other substances increases (OSAP, 1990c).

The serious consequences of inhalants make this trend alarming. The results of inhalant use may be as grave as severe physical harm or death. Use of inhalants can result in organic brain damage, a condition that can be very severe, and possibly permanent. The inhaled vapors can cause fatty brain tissue literally to melt (Texas Commission on Alcohol and Drug Abuse, 1991). Various inhaled substances can cause coma or convulsions. Other risks include respiratory depression, cardiac arrhythmia, and irreversible damage to the kidneys, liver, and bone marrow. The sniffing of gasoline has caused lead poisoning, which can have lasting adverse effects on an individual's physical and emotional development.

It is theorized that these high rates of substance abuse among Native Americans are related to socioeconomic conditions including poverty, prejudice, and lack of economic, educational, and social opportunities. Family influences also are conjectured to play a significant role in early use of substances (OSAP, 1990c).

In recent years, drug use has declined among Indian youth as it has with other youth populations in the country, especially among those who were light users. However, rates for heavy users have tended to remain high (OSAP, 1990c).

Formal studies among Native American populations are somewhat limited, and most have been conducted on reservations rather than in community settings. Some research has suggested that intervention efforts need to be aimed at enhancing the health of Native American families. Successful programs have included key elements of community ownership, agency collaboration, and tribal determination (OSAP, 1990c).

Asian and Pacific Islander Americans

Asian Americans include a diverse population of people from Japan, China, Korea, India, the Philippines, Vietnam, and other Asian countries. This collection of people is one of the fastest growing minority populations in the United States (OSAP, 1990b).

Statistical evidence of alcohol and other drug use among Asian Americans is generally low compared with other subgroups of the population. However, substance abuse may be greater than survey reports indicate, as Asian Americans tend to handle problems within the family and community. They are not as likely to use public treatment services, as there is a stigma attached to seeking professional help in their culture (OSAP, 1990b).

Overall, Asian Americans have fewer alcohol-related problems than any other major ethnic group. However, there are indications that the use of alcohol and other drugs may be increasing. Traditionally, drinking takes place in controlled settings; rarely do they drink alone. However, drinking patterns among various groups of Asian Americans differ greatly (OSAP, 1990b).

Chinese Americans accept drinking among the elderly for health reasons. Chinese American youth are more likely to use Quaaludes than other ethnic groups. However, they have lower rates for using heroin, PCP, amphetamines, and Valium (OSAP, 1990b).

Hispanic/Latino Populations

Hispanic/Latino populations in the United States include Mexican Americans, Puerto Ricans, Cuban Americans, El Salvadorans, Nicaraguans, persons from the Dominican Republic, and immigrants from other Central and South American countries. Spanish speaking people are not homogeneous. Rather, those from each country bring with them distinctive habits, customs, values, and cultural traditions (OSAP, 1990d).

Hispanics/Latinos constitute the second largest minority group in the United States population. Currently, they represent about 8 percent of our total population, but if trends continue, they will be the largest minority group in the early twenty-first century. Drug abuse among Hispanic/Latino youth has been significantly associated with high school dropout rates (OSAP, 1990d).

Hispanic/Latino youth appear to use alcohol at a rate similar to that of Anglo youth. Boys are more likely to begin drinking at a younger age and to drink more than girls. For other drugs, the level of use among Hispanic/ Latino youth is comparable to, or slightly less than, that of Anglo youth. Hispanic/Latino youth aged 12 to 17 are more likely than Anglo or African American youth to have used cocaine (OSAP, 1990d).

Specific recommendations for treatment planning include (OSAP, 1990d):

• targeting the whole family and religious leaders because of the strong ties and influences these entities have;
• developing materials and programs in Spanish and making them culturally appropriate; and
• targeting efforts through community leaders and organizations to increase the acceptability of programs.

African Americans

Among high school students, African American youth have lower levels of reported drug and alcohol use compared to other groups. Surveys also indicate that African American youth begin the use of alcohol and other drugs at later ages than the general population. However, the rate of substance abuse among African American school dropouts is not clear (OSAP, 1990a).

Yet, alcohol and other drug use is a leading health and social problem for African Americans. Among adult populations, African American women tend to abstain from alcohol use at higher rates than white women. For African American and white men the patterns are more similar. When alcohol-related health problems are examined, such as cirrhosis of the liver and certain types of cancer, there is a greater prevalence among African American men than among white men (OSAP, 1990a).

Although African Americans are more likely to abstain from using alcohol, studies have found that those who do use are also more likely to use other drugs concomitantly. The relative availability of illegal drugs in the inner city may play a role in drug use among African American youth. Other factors may include alcohol advertising targeted at African American consumers, the wealth displayed by local drug dealers, and media attention given to alcohol and drug use among African American entertainers and sports figures (OSAP, 1990a).

The relationship between alcohol use among African American youth and crime is well-documented. Delinquent behavior appears to begin before drug use. However, those who use alcohol are more likely to engage in delinquent behavior than those who do not drink. Cocaine use, which is on the rise in some African American neighborhoods, appears to be associated with higher crime rates. Researchers have found that drug-using African Americans primarily tend to victimize members of their own community (OSAP, 1990a).

Rural AOD Abusers

Treatment of AOD abusers in rural settings presents a variety of special issues and problems:

• Rural treatment programs may be more expensive to administer than metropolitan programs. Although fewer persons may need a particular program or service, the cost of operation may be similar because comparable staff, facilities, and supplies are needed. This results in higher per-patient treatment costs.
• Treatment may not be as accessible due to the distance patients and program staff must travel to meet.
• Programs may not have a buy-in from the community or community agencies. In some rural communities, there may be a stigma related to alcohol and other drug addiction that is not as noticeable in urban areas. Persons needing treatment may be more visible than they would be in a more populated area; therefore, there may be more concern about confidentiality on the part of those needing treatment. The importance of treatment may not be understood or supported as well as in metropolitan areas with greater resources.
• There may be a lack of trained and experienced staff in the area of AOD issues. Rural areas may have a difficult time attracting and holding such professionals. Limited resources mean professionals in many agencies must perform a variety of tasks. Individuals in education and health care may not have sufficient time or expertise to devote specifically to drug issues (United States General Accounting Office [GAO], 1990).

These findings are substantiated by three reports, conducted by Edwards and Egbert-Edwards (1988) and the U.S. Department of Health, Education, and Welfare (1977 and 1978).

The GAO conducted a study of several issues related to substance abuse in rural areas in preparing a report for Congress. The GAO (1990) found that:

• Alcohol is by far the most widely abused drug in rural areas.
• Prevalence rates for some drugs (such as cocaine) appear to be lower in rural than nonrural areas. Prevalence rates for other drugs (such as inhalants) may be higher in rural areas than elsewhere.
• Total substance abuse (alcohol abuse plus other drug abuse) rates in rural States are about as high as in nonrural States.

It is clear that treatment has as vital a role to play in rural areas, as it does in metropolitan, urban areas.

Homeless and Indigent Persons

Several studies have assessed the rate of drug and alcohol disorders among homeless populations. Although methodological, geographical, and definitional differences among the studies yield varied results, those with alcohol problems range from 2 percent to 86 percent while those with drug problems range from 2 percent to 70 percent. Tenable estimates of the prevalence of alcohol abuse among homeless persons range from 30 percent to 40 percent. Similarly, drug abuse is considered to affect approximately 10 percent to 15 percent of the homeless population (McCarty, Argeriou, Huebner & Lubran, 1991, p. 1139). Dually diagnosed homeless persons with severe mental illness and substance use disorders comprise 10 percent to 20 percent of the homeless population (Drake, Osher & Wallach, 1991, p. 1149).

Families with young children are among the fastest growing segments of the homeless population. Today's homeless cohort also contains a much higher proportion of single women than in the past. Blacks and Hispanics are over-represented among the homeless, compared with their numbers in the general population. About half to three-fourths of homeless adults have an alcohol, drug, or mental disorder. As a group, the homeless are one of the most disadvantaged and underserved groups in our society. One study found that 64 percent of severely mentally ill, substance abusing, homeless people are likely to have spent time in jail. For some, jail is a secure, structured facility for sometimes difficult-to-manage persons whose needs are not met elsewhere (Buckley & Bigelow, 1992; Fischer & Breakey, 1991; Levine & Huebner, 1991; McCarty et al., 1991).

Other indigent persons have similar problems. They may have an address, but housing may be substandard. Ethnic minority populations, women, and children are over-represented among those living in poverty. Those who are poor, whether homeless or not, are affected by the multiple risks experienced by other special population groups. These often include minority status, sociocultural disadvantages, stigma and discrimination, lack of access to health and mental health services, inadequate education, involvement in the criminal justice system, and lack of employment opportunities.

The use of alcohol and other drugs may be a reaction to the exigencies of their lives–a way of escaping from or coping with daily problems. For some, substance abuse represents a response to life situations, while for others it has precipitated a downward spiral of quality of life and opportunities.

Lack of financial resources compounds the problem of treatment for substance abuse. Without insurance or other means of payment, many are not eligible for treatment programs. In some cases, homeless and other indigent persons also do not qualify for publicly supported programs. Bureaucratic procedures and technicalities, such as needing to provide a home address, may get in the way of accessing services. Concomitantly, many have a distrust of public programs and professional service providers and will not actively seek help. Programs need to be proactive in reaching out to such individuals and to be sensitive to their cultural values and perceptions about seeking help. In some cases, paraprofessional outreach workers have been effective in making initial contacts with these persons and helping them negotiate complex service systems.

Prostitutes

The use of some drugs is consistent with income-generating crimes, including prostitution, because the drugs are addictive and expensive (Nurco, Hanlon & Kinlock, 1990). Although more commonly associated with females, prostitution is an activity engaged in by both genders. Fewer research findings are available about male prostitution, but some writers contend that patterns and problems related to homosexual prostitution are similar to those of heterosexual prostitution (Verbraeck, 1988). Two recent studies have provided more information about male prostitutes.

In one investigation, 211 male street prostitutes were interviewed. Results indicated that daily use of multiple substances was normative among the respondents. Economic dependence on prostitution and use of drugs and alcohol were correlated. The subjects' use of substances increased significantly while they were engaged in acts of prostitution. Psychological distress and conflicts about sexual orientation also exacerbated their use of substances (Morse, Simon, Baus, Balson & Osofsky, 1992).

A second study examined high risk sex and drug use among 446 male street youth, ages 14 to 23 years, in Hollywood, California. Prostitution activity was most common among older gay identified males. Their most predominant risk factors for HIV transmission included inconsistent condom use, high risk sexual behaviors, large numbers of sexual partners, intravenous drug use, and the use of drugs and alcohol during all sex (Pennbridge, Freese & Mackenzie, 1992).

Winick (1992) differentiates between "higher-status" and "lower-status" female prostitutes, indicating that for the former (e.g., call girls), prostitution usually precedes addiction, while for the latter (e.g., streetwalkers), addiction often occurs first. Pimps may maintain control of their prostitutes by controlling their supply of heroin. When pimps are addicted, they may use their prostitutes' earnings for their own supply of drugs. Often, the same individuals control both the prostitution and the drug sales in a particular area (Winick, 1992).

It is estimated that 125,000 to 200,000 male and female youth become involved in prostitution each year. Many, although not all, of these adolescents are runaway or homeless youth. Approximately 1 million teenagers run away from home annually. There is no typical runaway or homeless youth. However, many are the casualties of dysfunctional families and are escaping stressful environments, including physical or sexual abuse, chemically dependent parents, family crises such as divorce or death, and school problems. Many of these youth have emotional problems, as well. They often begin their illegal activities with shoplifting and petty thefts before moving into drug use, prostitution, and drug trafficking. It is estimated that homeless youth participate in street prostitution to support themselves and their drug habits at more than 100 times the rate of other youth (Haffner, 1987; Hersch, 1988; Johnson, 1988; Joseph, 1992).

There are multiple hazards associated with prostitution. For females, there is the possibility of pregnancy and associated risks. Arrest, criminal prosecution, and sanctions are also dangers associated with prostitution.

Although some studies indicate that prostitutes do not constitute a special risk category for HIV disease, there are certain subgroups of prostitutes who are at increased risk. These include those with lower educational levels; those who do not use condoms; those engaged in drug use, especially injecting drugs; and those who are homeless (Joseph, 1992; Shaw & Paleo, 1986; Winick, 1992).

There are several patterns of violence among prostitutes using drugs. Drugs may result in violence when use by prostitutes has a negative effect on their attitudes and they become irritable and hostile while using. Aggression, anxiety, suspicion, and fear associated with cocaine use are reasons for violence. Coming down from a cocaine high sometimes results in violence toward customers. Drug use also can lead to victimization of the prostitute by a customer because of clouded thinking. Systemic violence refers to aggressive patterns of interaction within the system of drug use and drug distribution. Some prostitution-related violence occurs from encounters between prostitutes and their pimps over territory and non-drug- related business. Other episodes of violence involve the income-generating needs of drug-involved prostitutes (Sterk & Elifson, 1990)

There is a clear connection between drug use and prostitution. Persons with a history of prostitution may need special consideration for treatment. Previous experiences, including rape and incest, must be dealt with in treatment. Intervention programs also may need to help these patients develop a healthy sense of sexuality (Winick, 1992).

Women

Women with alcohol and other drug dependencies have been understudied and have not received adequate treatment services. Most of the research on alcohol and drug abuse has been done on male populations, and only recently are studies also beginning to focus on women. Similarly, treatment programs have overwhelmingly been directed toward males; even when females have been included, their special needs often have been overlooked. One recent study confirmed that female alcoholics are likely to delay seeking treatment until their symptoms are severe compared with similar males. Women alcoholics also tended, more often than males, to enter treatment in mental health centers and other health care settings instead of in alcohol-specific treatment programs (Weisner & Schmidt, 1992). The unique problems of women needing substance abuse treatment include issues related to co-dependency, incest, abuse, victimization, sexuality, and problems with significant others. They also are likely to have special medical needs, including gynecological problems (Mitchell, nd).

Blume (1992) summarizes some of the differences in chemical dependency in women when compared with men:

• Alcoholic women begin drinking later than males, on average. However, one study found that women tended to begin using cocaine at earlier ages than other mood-altering substances.
• There are physiological differences in the way alcohol is absorbed and the amount of body water between men and women. Women can consume less of a substance than men and still experience comparable effects.
• Women who enter addiction treatment are more likely to have an alcoholic or addicted male partner or to be divorced or separated.
• A particular, stressful event is often cited by women as the beginning of problem drinking or drug use. Many report being victims of childhood sexual abuse or having a history of sexual assault.
• Chemically dependent women are more likely to have a co-existing psychiatric problem, especially depression.
• Chemically dependent females report a greater history of suicide attempts than males. Alcoholic women were found to attempt suicide four times more frequently than other women.
• Health and family problems more often motivate chemically dependent women to enter treatment. Men are more often influenced by job and legal problems.
• Although women drink and use illegal drugs less frequently than men, they are more likely to use prescribed psychoactive drugs.

Women have a complex array of personal, social, psychological, and cultural issues that accompany their substance abuse. They frequently have the responsibility of caring for children. Many are single parents, with concerns about the care and placement of children; the associated costs are often at the forefront of treatment decisions. Pregnancy is another important issue. There are significant risks to infants born to drug-involved mothers. In addition, treatment programs often do not want to incur the risks and liabilities associated with pregnant and parenting patients.

Many women have co-dependent relationships with men or significant others who are also drug-involved. In such relationships, each person needs and uses the other, often in ways that are unhealthy. Women generally have more limited incomes because of deficient employment and educational skills, and they are often economically dependent on their partners. They also may be emotionally dependent, making escape from drug-involvement even more difficult. Thus, they often do not have options for treatment programs requiring private insurance or other non-public sources of payment (Weisner & Schmidt, 1992). Typically, drug-involved women have low self-esteem and lack assertiveness skills, making it difficult for them to manage the complex treatment and assistance network (Mitchell, nd). Many also lack access to transportation.

Pregnant Addicts

It is estimated that about 11 percent of pregnant women may use illicit substances. Substance abuse during pregnancy increases the risk of problems for both the mother and the fetus or newborn. Cocaine use may result in malformations, growth abnormalities, and behavior problems. Neurologic abnormalities in children have also been linked to cocaine use by fathers. Cocaine has been found to decrease the count and movement, while increasing abnormalities, of sperm (Yazigi, Odem & Polakoski, 1991; Zellman, Jacobson, DuPlessis & DiMatteo, nd).

Use of marijuana during pregnancy represents a significant risk to the fetus. Marijuana crosses the membrane that envelops the fetus. Babies may develop abnormal nervous systems, and they may be smaller than non-exposed infants. Marijuana also is secreted in breast milk and can be toxic to a nursing infant. Some marijuana-exposed infants show signs of withdrawal, including convulsions (Cohen, 1985).

Fetal Alcohol Syndrome (FAS) consists of an array of problems that are highly correlated with alcohol use during pregnancy. Mental handicaps and hyperactivity resulting in learning, attention, memory, and problem-solving difficulties are among the most debilitating aspects of prenatal alcohol exposure. In addition, infants exposed to alcohol in utero are likely to be smaller and have characteristic facial features (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1991).

In a survey of all 50 States and the District of Columbia, it was found that no State currently has enacted legislation to test pregnant women for the use of illicit drugs (Adirim & Gupta, 1991). Goldsmith (1990) advocates mandatory treatment of drug-involved pregnant women although there are arguments against legal interventions with these addicts. Goldsmith argues that consuming illegal substances is an unlawful act that can result in harm to the infant and society. The costs associated with treatment of drug-exposed children diminish the resources available to all children. The most powerful pressure for bringing drug abusing women into treatment is the threat of legal sanctions. However, some fear that such measures will deter drug dependent women from seeking needed prenatal health care.

Treatment of pregnant women for substance abuse is crucial, but it can be difficult. There are some situations in which withdrawal from drugs, especially opiates, is dangerous to the fetus. Occasionally, it may be necessary to maintain a woman's addiction until after the birth (Mitchell, nd). See Chapter 8 for additional information.

There is a need for significantly expanded prevention and treatment capacity for pregnant and postpartum women and their children. These women have specialized treatment needs. They need prenatal care and improved nutrition, as well as child care and financial support. Identification and treatment of infectious diseases in both women and their infants is another important element of treatment. Treatment strategies must be developed that are culturally sensitive and appropriate for women from various minority and ethnic cultures. Other important considerations for treatment include drug-free housing, transportation, and skill development opportunities (Mitchell, nd).

Recommended considerations for treatment of women, especially substance using pregnant women, include the following (Mitchell, nd):

• Gender-specific services must be provided in a non-judgmental environment. Services should respond to women's needs regarding reproductive health, sexuality, relationships, and sexual and physical abuse.
• Comprehensive treatment for substance use should be available on demand.
• Service components should include:
  - vocational services
  - educational services
  - inpatient drug treatment and drug-free transitional housing for women and children
  - transportation
  - child care and baby-sitting services
  - comprehensive medical services
  - financial support
• Service providers need continuing training and technical assistance and need to engage in collaborative efforts to ensure comprehensive programs.

Infants and Children

It is estimated that of every 1,000 babies born in the United States, between one and three have Fetal Alcohol Syndrome. Many more will be affected by alcohol in utero but do not have all the characteristics that define Fetal Alcohol Syndrome (Office for Substance Abuse Prevention, 1989). The primary traits of Fetal Alcohol Syndrome, as mentioned previously, include mental retardation, growth deficiency, and characteristic facial features. Even in children without these pronounced characteristics, indicators of prenatal exposure to alcohol may include problems such as lower IQs, aggression, hyperactivity, and sleep disorders (Chiang & Lee, 1985).

It is estimated that between 554,000 and 739,000 infants are exposed prenatally to illegal drugs each year (Finnegan & Kandall, 1992, p. 628). In New York City, it is estimated that 80 of every 10,000 children born are addicted to chemicals (Doweiko, 1990). In utero exposure increases risks of premature births, still births and subsequent mortality, low birth weight, small head circumference, deformities, Sudden Infant Death Syndrome, and neurological damage, among others. These infants often require extensive care and may continue to present health and behavioral problems throughout childhood (Finnegan & Kandall, 1992).

HIV infection is another risk for infants of drug-involved parents. Transmission of HIV is docu-mented between mother and infant, either in utero, during delivery, or through breast milk. Mothers may be infected because of their own drug use or through heterosexual activity with HIV infected, drug-involved sexual partners. Although not all babies born to HIV infected mothers will develop AIDS, approximately 50 percent will. Whether or not a child develops AIDS, he or she is likely to experience difficulties because of the parents' infection. Often, HIV infected parents will die of AIDS, leaving young children to be cared for. For children who are infected with HIV, the medical care they need can be very expensive and, at times, painful. Often such children need alternative placements when parents and relatives cannot provide care for them, such as foster homes and special health care facilities.

Excessive use of alcohol or other drugs by parents also may affect the quality of care they are able to provide for their children, whether or not there has been in utero exposure to drugs and alcohol. Child abuse and neglect cases often have a substance abuse factor involved. Judges in these situations face difficult decisions concerning the protection of the children versus family preservation. The availability of treatment options and the willingness of parents to obtain treatment is often an important element in that judgment.

Juveniles

Although drug use in the general population of adolescents attending school and living at home has declined in recent years, there is sufficient justification to be concerned about youth. Dropouts constitute an estimated 15 to 20 percent of youth the age of high school seniors, and these youth tend to be at high risk for substance use and delinquency (Schinke, Botvin & Orlandi, 1991).

Youth who become involved in delinquent behaviors and the use of drugs and alcohol come from all social strata, both large and small communities, and healthy as well as dysfunctional families. They may be gifted or limited in intellectual abilities, have few or many talents, and vary markedly in personality. There is no easy predictor of delinquency or substance abuse.

Indeed, research indicates that a complex array of cognitive, psychological, attitudinal, social, personality, pharmacological, and developmental factors foster initiation of adolescent drug use (Schinke, Botvin & Orlandi, 1991). Some of the characteristics that are typical of adolescent development appear to increase the chances that some youth will at least begin the process of experimenting and taking risks with drugs, alcohol, and illegal behaviors. Young people are establishing their identity and independence. As a part of this process, they need to explore different behaviors and values. Experimentation and opposition to adult norms and values, within limits, is typical adolescent behavior. For some youth, however, these behaviors plunge them into a world of activities that can become very dangerous. The pleasure, thrill, or excitement may be so stimulating that they continue to seek it. For some, the acts of rebellion against parents or society are particularly satisfying. Others acquiesce to peer influences from youth who offer friendship and acceptance to those who will engage in similar activities.

Young people often feel invincible and invulnerable. They have difficulty understanding that they are not exceptions to the rules of drug use and delinquency. There is a tendency for youth to believe that they can somehow engage in certain behaviors but escape their negative consequences. Because of their limited future time perspective they tend to see themselves as always being as they now are: young, strong, and in control. Many cannot believe the negative impact of drug and alcohol use will affect them, even if they are acquainted with others in such distress.

There are a variety of problems that are affecting a significant portion of today's youth. The society in which today's youth find themselves is more violent and alienating than in the past. Family violence and abuse of children are increasing rapidly, or at least they are being reported much more frequently. However, reported incidents of abuse probably represent only a small proportion of the violence and abuse that is actually occurring, as these problems tend to be highly protected family "secrets." Physical and sexual abuse interfere with adolescent development and make it difficult for youth to achieve optimal physical and psychosocial maturation.

Cultural violence also is increasing. The problem of youth gangs and the violence they perpetrate is of grave concern. Many youth are carrying weapons, even to school. Substance abuse has grown remarkably among the adolescent population, and youth are beginning involvement at earlier ages than ever before. Drug involvement has many negative effects on youth, one of which is increased violence. Another form of violence is self-inflicted. The rate of adolescent suicides has been climbing steadily, as some youth find their current situations intolerable. Adolescent males are particularly vulnerable to violence, including homicide.

The number of runaway, thrown-away, and homeless youth is growing. These young people, who subsist on the streets by their wits, fortitude, and sometimes criminal activities, are at great risk for physical and psychosocial developmental problems. Their likelihood of encountering substance abuse, prostitution, delinquency, malnutrition, and disease is multiplied exponentially. Many youth run away or are pushed out of families that are abusive or so dysfunctional they cannot meet the needs that the youth present. With time, homeless youth will lose the potential for continuing their education or obtaining productive employment.

Adolescent sexual activity has increased rapidly, resulting in approximately 1 million teenage pregnancies annually. Through sexual behavior, youth are also placing themselves at risk for sexually transmitted diseases, some of which are deadly. Youth must be informed at earlier ages about sexuality and appropriate precautions.

These pressures on youth may be both the cause and the effect of characteristic adolescent development. Adolescents tend to feel invulnerable, often believing that bad things will not happen to them. Feelings of immortality and invincibility also are common. Impulsiveness is yet another common trait. These patterns lead to risk-taking behaviors, some of which have devastating results. Once certain thresholds are crossed, youth are unable to go back. They continue a downward spiral of more serious involvement in activities that further jeopardize their health and future well-being.

There are several reasons youth who enter the juvenile justice system are often involved with drugs. First, drugs cause individuals to engage in risky, destructive, and even violent behavior. In some cases, youth are so dependent on the drug that they will do anything to obtain it. They therefore commit income-generating crimes such as theft, drug trafficking, or prostitution. Moreover, these youth often come into contact with other juveniles or adults who are involved in drug use and crime. Such influential individuals in their lives may help steer them toward delinquent behavior. While drug use may contribute to a juvenile's tendency toward delinquency, it is also true that many juveniles are involved in delinquency before they begin using drugs. A direct cause-effect relationship between drugs and delinquency has not been substantiated.

The problem of adolescent substance abuse affects all systems dedicated to serving youth, as well as every community in the nation. Many look to the juvenile justice system for answers. Some believe there should be tougher penalties for drug and alcohol offenses. Some advocate diversion of youth to drug education and treatment programs–a more rehabilitative approach. A balance is probably more reasonable than the adoption of either extreme.

As with other special populations, alcohol- and drug-involved youth need treatment programs that are sensitive to their needs and appropriate for their developmental stage. Assessment is the first critical phase of treatment. The multiple assessment approach, including interviews, observations, specialized testing, and written reports, is recommended for obtaining the most valuable information for informed treatment planning (McLellan & Dembo, 1992). Treatment programs for youth should not merely duplicate programs that have been successful with adult groups. They need to be formulated with particular attention to adolescent developmental levels, family situations, educational needs, and many other factors. Appropriate interventions for youth may include (McLellan & Dembo, 1992):

• school-based prevention;
• drug education classes;
• outpatient treatment;
• partial hospitalization; and
• residential treatment.

Elderly Persons

The most common substance abuse problems for older persons include alcohol abuse and the abuse or misuse of prescription drugs. The rate of alcohol use among senior adults is generally lower than within the general population. Yet approximately 10 percent of elderly males and 2 percent of elderly females are heavy or problem drinkers (Williams, 1984).

Older persons have a decreased tolerance for alcohol that may cause adverse effects on the central nervous system, heart and circulation, liver, gastrointestinal tract, and kidneys. Some elderly persons experience sleep disturbances and have difficulty handling stress. The combined effects of aging and alcohol use affect the body's resilience, including physical, emotional, and psychological components (Williams, 1984).

There are normal changes in the central nervous system of older persons, including increased reaction time and confusion. Alcohol, a central nervous system (CNS) depressant, exacerbates these problems and can result in decreased intellectual functioning (Williams, 1984).

The elderly consume more medication than any other age group. There are special risks related to these medications. Older persons living alone may make errors in taking medications (Williams, 1984). Frequently, senior adults are being treated by different medical specialists for a variety of problems. Simultaneous use of certain drugs may be contraindicated; however, older persons may not tell their physicians about other medications they are taking. Interaction of alcohol with other drugs also may result in serious consequences for older persons.

Normal metabolic changes in aging may result in the body's inability to excrete drugs at the same rate as younger persons. Thus, it is possible to build up toxic amounts of drugs when older persons take the same doses of some drugs as younger adults. Some physicians have not received special training about the medical needs of older patients and are not as aware of medication management issues as is desirable. Many older persons face personal losses and social problems in the aging process. Incomes are often limited, while inflation raises the costs of most basic needs. Medical costs often increase for older persons as various chronic illnesses are common among the elderly. Many older persons have very supportive and caring families; however, some elderly citizens are victims of loneliness, neglect, and abuse. Many of these problems may result in older persons turning to alcohol for comfort or escape. Medication compliance is another difficult issue. Various factors can contribute to inappropriate use of drugs, including poor vision and short-term memory impairments. Purposeful misuse may include exchanging prescribed medications with friends or consuming more than the prescribed amount.

Physically Challenged Individuals

Physically challenged persons include those with numerous disabilities such as motor abilities, visual impairments, speech and hearing difficulties, and many others. In addition to the physical difficulties these persons encounter, they frequently have other problems. Their disabilities often place them at risk of socioeconomic deprivation. They may be excluded from, or unable to participate in, training and job opportunities that would allow them to earn more sufficient incomes. Also, some may have high medical expenses because of costly treatments, medications, equipment, and prostheses.

In addition to these problems, physically challenged persons continue to deal with prejudices and stigmas. These range from outright discrimination in jobs and facilities to more subtle staring and avoidance by others.

Because of physical and emotional pain, some physically challenged persons are at risk of alcohol and other drug abuse. In some cases, this may be an attempt to self-medicate to overcome physical or emotional pain with alcohol or other illicit drugs. Concomitantly, compliance with prescribed medication regimens may be an issue for some individuals. Many drugs of abuse also have legitimate medical uses, and in some cases it is the responsibility of the patient to administer these correctly.

Conclusion

The United States is composed of many diverse groups. Alcohol, drug abuse, and related diseases often afflict members of disadvantaged groups at rates that are higher than those for majority group members. Socioeconomic status, ethnicity, gender, and several other variables are related to certain patterns of substance abuse.

A variety of treatment options that are age- and gender-appropriate, culturally sensitive, and relevant for specific socioeconomic groups are needed in every community and region. This is an essential aspect of patient-treatment matching. Comprehensive treatment services are vital, as most chemically dependent persons have multiple problems and needs.

Culturally sensitive and thorough assessments are the first essential element of treatment. Appropriate treatment matching will be the most cost-effective approach to the problems of substance abuse. If patients' needs are not adequately assessed and met in the treatment setting, they will not remain in treatment and progress to recovery. That not only wastes the money used for their treatment, but deprives others from using those treatment spaces.

Major consideration must be given to systems coordination and collaboration and communication among service providers to achieve effective treatment matching. A network of well-run programs that use a variety of treatment approaches and serve various patient populations is needed. Allocating resources and establishing priorities are major considerations for State and local leaders.

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Last Updated 11-7-02