A Theoretical Framework
for Demand Reduction --
Summary of Presentations
Co-Moderators: Dr. Hoover Adger Jr., and Dr. Roberto Tapla-Conyer
Treatment
Dr. Shirley Coletti
President, Operation PAR, Inc., USA
Dr. Coletti began by stressing the importance of this joint effort to attack drug abuse at all levels, starting with drug education and prevention in all schools and at all grade levels. She noted that the casual user's demand for alcohol or drugs is markedly affected by the perceived harm these substances pose. This is often mediated by such events as the death of a famous athlete from drug use or changes in social sanctions related to use. Unfortunately, in the United States, she explained, drug use is often glamorized by the mass media and advertising. She called for strong public awareness campaigns to offset these negative influences.
Dr. Coletti maintained that accessible treatment is essential to reduce chronic drug use. Chronic users, she noted, rarely discontinue their use without treatment. Thus, services need to be integrated into a coordinated, community-wide strategy for reducing drug problems. This strategy must include economic development opportunities, physical and mental health care, changes in the criminal justice system, and support from other key institutions in both nations.
Further, comprehensive treatment services must be available to all who need them, including adolescents and pregnant and postpartum women. Unlimited treatment access and strong prevention efforts directed toward even younger children are important in demand reduction.
Dr. Coletti noted that 15 years ago we saw fairly functional families; less incest, violence, criminality, and promiscuity; and only limited access to drugs. Now, she claimed, we often see second- and third-generation substance abusers displaying a much wider range of pathology. She cited the case of a 14-year-old girl with a 12-year history of drug abuse that began with her parents blowing marijuana smoke into her mouth at the age of 2. By age 11, she had become a prostitute in order to survive and to obtain drugs. Dr. Coletti claimed that such cases, once rare, are now common. Children having children, who must then raise themselves, are America's most serious challenge. She cited statistics revealing that the parents of some 6.2 million children reported illicit drug use in the month preceding a recent survey.
Dr. Coletti also cited the case of a boy who had 25 adverse drug-related encounters with his school and with the justice system but who had never been referred for drug treatment. Ignoring such children rarely works. She called instead for more family counseling, mental health services, academic and vocational assistance in addition to drug treatment. Similarly, she maintained, pregnant women and those with children need multiple services such as parenting skills training, moral development, and help in integrating into their communities.
As Dr. Coletti explained, her organization, Operation Parental Awareness and Response (PAR), stresses parental involvement. It also works to increase the family's ability to cope and teach their children values, morals, citizenship, and social skills. Additionally children with deficient academic skills are helped to succeed in school.
Dr. Coletti concluded by noting that both nations need to fund process and outcome research to reinforce what works and to eliminate what does not. She stated that research has shown that treatment improves health, reduces health care costs, and leads to more productive citizens. We must therefore work toward demand reduction, one person, one family at a time, she said. If there is "excess money" in State and Federal budgets, it should be used to provide unlimited access to treatment, because strong prevention and treatment are important solutions to demand reduction.
Dr. Victor Guisa Cruz
Director, Treatment and Rehabilitation
Youth Integration Centers, Mexico
Dr. Guisa noted that Mexico, like other countries, regards drug abuse as an urgent public health problem. He cited a recent National Addiction Survey which found that 3.9 percent of the Mexican population, or approximately 1.6 million people, have used drugs one or more times. He also claimed that patient reports covering the years 1990 to 1996 indicate some 50,000 Mexicans sought treatment. Most (60 percent), he stated, were between the ages of 15 and 20; men outnumbered women 10 to 1. Further, initial consumption of drugs usually began between ages 10 and 19, and 60 percent of these patients indicated that had used drugs for more than five years. Seventy-two percent had used marijuana, and 51 percent had used inhalants; and while use of these drugs remained stable over the period studied, cocaine use increased from 12 to 40 percent. Designer drugs also are appearing more frequently in Mexico, Dr. Guisa noted, and there are concerns that risk factors for HIV infection are increasing as well.
Drug dependency clearly has complex causes, so our management of the problem demands a complex response.
Dr. Guisa stressed the importance of health teams being well informed about the complications of drug use, the importance of early diagnosis, and the need for specialized treatment. Because substance abuse has a complex etiology, he stressed the importance of studying genetic, biochemical, neurophysiological, and socioenvironmental factors. As he noted, there are now multi-modality treatment alternatives that can be applied by multidisciplinary teams to achieve successful treatment outcomes. Given that drug use is multifaceted, he indicated that treatment approaches must be similarly multidimensional. Psychiatrists, psychologists, social workers, educators, religious leaders, and anthropologists can all contribute to effective treatment, he claimed.
Dr. Guisa asserted that both emergency treatment for abstinence syndromes and specialized long-term treatment programs are needed. Treatment should include the use of medications to counteract the effects of drugs or other factors contributing to their use (e.g., depression and anxiety). He also called for drug maintenance programs to replace illicit drugs with controlled substances (e.g., methadone for street opiates) and claimed that treatment should increasingly include techniques to improve family and social function, residential treatment, community therapy, and self-support elements. Drug dependency clearly has complex causes, Dr. Guisa stressed, so our management of the problem demands a complex response.
