DRUG ABUSEinsurers tend to discriminate against persons with
substance abuse problems and there are inade-
quate treatment resources.
Current treatment for drug abuse, in addition
to withdrawal, ranges from psychotherapeutic in-
terventions (provided in both inpatient and outpa-
tient settings), pharmacology agents, and various
forms of milieu therapy. It frequently includes
information on relapse prevention. Psychothera-
py is often used in combination with other forms
of treatment, and is provided both on an individu-
al and group basis by therapists trained in medi-
cine, psychology, social work, nursing and educa-
tion. Pharmacological treatments include approaches,
that substitute or block the effect of an abused
substance, such as methadone maintenance for
heroin (Ball and Ross 1991). Milieu therapies in-
clude a variety of residential programs where drug
abusers can learn or relearn how to live substance
free. Although some relatively short-term hospital-
based programs exist (particularly for those with
independent resources to pay for such services),
the most common milieu consists of longer-term
therapeutic communities such as Phoenix House,
where drug users live in a setting in which they are
closely monitored. The residents’ progress through
the several levels of the program’s hierarchical
social structure depends on their ability to imple-
ment the program’s rules for ‘‘right living’’ (De
Leon 1997).
Although often not considered a treatment,
various fellowship groups deriving from the Alco-
holics Anonymous model are widely used by drug
abusers. Thus, for example, groups such as Nar-
cotics Anonymous, Cocaine Anonymous, and par-
allel groups for spouses and parents of drug users
exist in almost every community. Such groups,
which have no professional staff and rely on the
reinforcement of abstinence, support drug abus-
ers in maintaining drug-free lives and help family
members aid their drug-abusing relatives. Many
treatment programs encourage their patients or
clients to participate in such a twelve-step fellow-
ship simultaneously with the treatment period or
after treatment is completed.
Although substantial resources have been de-
voted to treatment outcome research, our knowl-
edge of who does best in what treatment is limited.
Particularly for cocaine, the use of which can lead
to dependence in a short period of time, effective
pharmacological treatments are not available. A
combination of strategies is often most effective
especially if it recognizes that drug abuse is a
chronic relapsing disorder that is likely to include
multiple treatment failures on the way to an ulti-
mately favorable outcome. Of the treatment ap-
proaches to drug abuse, milieu treatments have
been among the most intensely studied. For those
able to participate in such programs, they can have
extremely high rates of relatively enduring posi-
tive outcomes. Whatever the treatment modality,
it must include job readiness, habilitation and
vocational rehabilitation, and other dimensions
that will enable the former user to function effec-
tively in the modern information-oriented com-
munity and economy.PREVENTIONIn the late 1980s, the social problems associated
with drug abuse, particularly in terms of the pos-
session and sale of cocaine in urban areas, were
perceived to have reached crisis dimensions and
there was a marked increase in criminal justice
efforts to control substance use. Another positive
response was a renewed emphasis on the preven-
tion of drug abuse and the collateral development
of broad-based community strategies designed to
reduce demand for illicit drugs. Currently, such
demand-reduction efforts are undergoing system-
atic study in several long-term longitudinal public
and private programs.There has been a transformation in views of
substance abuse as we have moved from a focus on
individual pathology to programs that engage com-
munity institutions. Such efforts aim to change
norms about substance use through the involve-
ment of community members and the integration
of the substance-abuse programs pursued by pub-
lic and private agencies. The 1990s saw the expan-
sion of community-based programs to include a
broad range of institutions, including the police
and courts, the voluntary sector, as well as the
media (Falco 1994). Fostered by the government’s
Center for Substance Abuse Prevention (part of
the Substance Abuse and Mental Health Adminis-
tration) and efforts of the Robert Wood Johnson
Foundation, the country’s largest health founda-
tion, hundreds of communities are engaged in
broad-based efforts to change the culture within