Archival Content: 1999-2005

HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers

Drug Treatment

Drug dependence is identified through behavioral and physiological symptoms and best treated by a multidisciplinary approach. Outcomes are determined, in part, by a number of interrelated factors, including: (1) characteristics of the individuals seeking treatment, including their level of "readiness for treatment"; (2) the treatment approach used and services provided; and (3) elements that affect the individual's adjustment to his or her environment once treatment is completed. No single treatment approach is effective for all persons with drug problems. An integrated system of treatment programs, containing a full range of treatment types, intensities, and cultural competencies is essential (Selwyn et al., 1995).

The last decade of evaluation research on drug treatment has demonstrated its overall effectiveness (Gerstein et al., 1990; Pickens et al., 1991). For example, a large pre- and post- treatment comparison study of 649 adult alcohol-, cocaine-, and opiate-dependent patients admitted to 22 public and private treatment programs showed participant improvement in seven areas: alcohol and drug use as well as medical, legal, employment, family/social, and psychiatric problems (McLellan et al., 1994). Other key studies evaluating alcohol treatments (Moos, 1974; Moos et al., 1990), drug abuse treatments (Hubbard et al., 1989; Simpson et al., 1980), therapeutic community treatment (DeLeon, 1984), and methadone maintenance treatments (Anglin et al.,1989; Ball et al.,1988; Novick et al., 1990) also have shown significant and pervasive changes among substance-dependent patients following standard treatments. A review of the data on the effectiveness of drug treatment can help prevention planners and program managers decide which HIV prevention interventions would best serve drug users and their sex partners.

Drug Treatment Services

Some people who have become dependent on drugs are able to stop using on their own or with the assistance of family, friends, church, or members of their community. Many more, however, need help from specialized counseling, support, and/or medical therapies. Drug abuse treatment programs differ in their philosophy, setting, duration, and approach. Most programs use some type of "service continuum" based on the concept that treatment, like substance-related disorders and recovery, is an ongoing process.

Drug treatment programs provide an important opportunity to conduct HIV prevention with drug users. Understanding the unique structure, approach, and philosophy of drug treatment services within a community allows prevention planners and program managers to support collaborative efforts with programs that have built-in access to drug users and their sex partners. In addition, drug treatment providers can become key allies in supporting community-based HIV prevention programs for drug users. Drug users benefit from services that address both HIV and drug-related risks.

According to the National Academy of Sciences, an estimated 5.5 million people need drug treatment, although it is available for only a fraction of them (Gerstein et al., 1990). The services that are available differ in their approaches and components. They can be divided into six major categories of programs: (1) detoxification; (2) inpatient; (3) therapeutic communities; (4) outpatient; (5) methadone maintenance; and (6) self-help.

Detoxification programs. Detoxification ("detox") programs are medically supervised programs in which drug users are weaned from their physical dependence on drugs, such as heroin, cocaine, and alcohol. Although there are a few outpatient detox programs, most detoxification occurs at inpatient facilities where a participant's progress can be monitored carefully.

In most detox programs, medication is used to lessen the severity of withdrawal symptoms. For users of heroin and other opiates, oral methadone (a synthetic opiate), is used to limit the discomforts associated with the abrupt discontinuation of a drug. The length of stay in a detox program often hinges upon which drug the patient is addicted to, which detoxification approach is used, and any restrictions established by health insurance plans.

Inpatient programs. Housed in hospitals or specialized treatment facilities away from the user's natural home environment, these programs provide drug users in need of intensive treatment with continuous care and supervision.

Therapeutic communities (TCs). TCs are peer-based, residential treatment settings designed to help clients alter, modify, and re-learn behaviors. The length of treatment varies from 18 to 36 months. Many therapeutic communities offer a wide variety of educational, medical, legal, social, and psychological counseling services, all of which are coordinated under the auspices of a basic self-help model. The TC approach is applied in a variety of settings, including community-based residences, hospitals, homeless shelters, and prisons. Most TCs have specific rules and norms that apply to both clients and staff. Exhibit C describes some basic components of TC programs.

Exhibit C: Basic Components of a Therapeutic Community (TC) Program

Community separateness		Usually housed in a location separate from other programs and drug-related environments.
Community environment		Environment designed and organized to promote a sense of commonality and collective activity.
Community activities		Treatment and services are provided within the context of the peer community and all activities are programmed in groups.
Peers as community members		Individuals who reflect the value and teaching of the TC, demonstrate the expected behavior, and who are viewed as role models.
Staff as community members		Staff are a mix of recovering professionals and other professionals who must be integrated through cross-training in the program and community approach.
Structured day		Each day has a formal schedule of therapeutic and educational activities with fixed times, routine procedures, and prescribed formats.
Phase format		Individual treatment plans are organized into phases that reflect a developmental view of the change process; emphasis is on incremental learning at each phase, which moves the individual to the next stage of recovery.
Work as therapy and education		Consistent with the self-help approach, all clients are responsible for the daily management of the facility.
Peer encounter groups		A peer group process is used to increase individual awareness of specific attitudes or behavioral patterns that need modification.
Duration of treatment		Length of individual treatment depends on stage of recovery.
TC concepts		An organized curriculum focused on the TC perspective, particularly its self-help recovery concepts and view of right living.
Maintenance of recovery		Development of relationships and a new social network needed to sustain recovery after treatment. Source:DeLeon,1995.

Outpatient programs. These programs serve about half of all those in treatment for drug and alcohol problems. Outpatient care is the least intensive form of treatment, and has fewer restrictions than inpatient or residential programs. This type of treatment is most suitable for people who are employed, have a stable and supportive social and family environment, honestly acknowledge their problem with drugs, and sincerely desire help in stopping their drug use. Outpatient program services range from drop-in centers to individual and group counseling sessions. Some outpatient programs provide educational, medical, psychological, and rehabilitative services. Patients receiving outpatient treatment must be highly motivated, particularly if environmental factors or personal relationships are conducive to triggering a relapse.

Methadone maintenance treatment programs. These programs provide outpatient services for those addicted to opiates, such as heroin, by offering methadone in combination with counseling. Dosages of methadone range from approximately 20 milligrams to more than 100 milligrams daily. A daily dose, which has a "half-life" of one to two days, stabilizes the patient until it is time to receive the next dose. At a sufficiently high dosage, methadone blocks the euphoric "rush" caused by heroin and other opiates, although it has no inhibitory effect on stimulants, such as cocaine.

Methadone maintenance programs have been proven to reduce opiate use, thereby enabling users to lead more productive lives. Some people have regularly taken part in methadone maintenance programs for 10 to 20 years with very good results. Some programs use methadone as one component of a planned course of treatment in which the methadone dosage is progressively reduced to zero. Completion of treatment with methadone usually is followed by on-going counseling designed to help former users remain abstinent.

Self-help or "12-Step" programs. The most familiar example of the self-help model is Alcoholics Anonymous (AA). The AA model has been adapted by self-help organizations for drug users such as Narcotics Anonymous (NA) and Cocaine Anonymous (CA). Meetings, fellowship, and mutual support are at the core of all these self-help groups. In a typical meeting, members gather to discuss their past or present problems with alcohol and drugs. They also give testimonials about their application of "the 12-step method" in bringing positive changes to their lives. By sharing their stories and hearing others describe their "powerlessness over the disease of addiction," participants obtain the support, fellowship, and motivation needed to maintain their recovery.

Self-help meetings provide a much-needed atmosphere of mutual support from others struggling with drug abuse or dependence. Such support can be very helpful, particularly for those in the early phases of recovery. Participants may attend several meetings a week, or as often as once or twice each day. The common goal for all participants of AA, NA, and CA is total abstinence. Typical meetings include celebrations of the "anniversaries" of those who have been "sober" or "clean and serene" for intervals of a month, six months, a year, and each anniversary thereafter.

AA, NA, and CA are member-operated, nonprofit organizations. The organizations themselves arrange for a place to conduct meetings, distribute literature, and provide the structure for the meeting. Although the 12-step programs themselves are not considered "formal" drug treatment programs, they are often major factors in helping drug users control their use of drugs.

HIV Prevention and Drug Treatment Programs

Typically, drug treatment programs are not considered prevention programs-treatment is usually applied when primary prevention fails. In the case of drug abuse treatment, however, there is real potential for treatment to achieve primary HIV/AIDS prevention goals, given the close association between drug use and HIV infection. By effectively treating drug use, direct and indirect risks of HIV infection can be reduced.

Data from the past ten years have clearly established an association between participation in treatment and lower risk of HIV infection. For example, an examination of self-reported risk behaviors of IDUs in treatment and out of treatment has shown significantly lower rates of risk behaviors (e.g., drug injection, needle sharing) practiced by drug users who are in treatment (Abdul-Quader et al., 1987; Ball et al., 1991; Caplehorn et al., 1995). These self-reported behavioral differences are consistent with studies of HIV incidence/prevalence and treatment participation, which have shown that participation in treatment programs that use opiate substitution (usually methadone) is associated with lower seropositivity rates (Metzger et al., 1993; Moss et al., 1994; Serpelloni et al., 1994).

In addition to being an effective HIV prevention program, drug treatment programs provide an ideal opportunity to reach drug users and their sex partners with a variety of HIV prevention interventions over a period of time. As one of the few organized social institutions with access to drug users at risk of HIV infection, treatment programs have in many ways become community-based "staging areas" for risk reduction interventions directed at IDUs (Metzger, 1997). Even though drug users in treatment represent only a minority of active drug users, there is a growing awareness that individuals in treatment provide access to a much larger community of drug users who are not in treatment. This is due to the fact that drug use often takes place in small groups or within social networks of drug users.³ Several studies have found that drug users currently in treatment are effective peer contacts who can conduct street outreach and disseminate prevention information and materials to their social networks of active drug users (Birkel at al., 1993; Latkin et al., 1996).

There has been much debate, however, as to the nature of HIV prevention programs within drug treatment programs. Many drug treatment program administrators believe that it is the program's responsibility to educate clients about how to protect themselves from HIV infection, including how to disinfect needles and syringes in the likelihood that the client may relapse during or after treatment. Others argue that risk reduction without abstinence violates the core principles of drug-free treatment and recovery.⁴

Drug treatment program administrators and staff can be valuable sources of expertise and support to prevention planners and program managers. Building these links requires a sensitivity to the various approaches and perspectives of those who work within the drug treatment system. Exchanging ideas and philosophies with drug treatment service providers can help pave the way for a coordinated, streamlined, and cooperative approach to HIV prevention community-wide.

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3. The social contexts of drug use are discussed more fully in PART 2: DRUG USE, SEXUAL BEHAVIOR, AND HIV RISK.
4. Issues related to the debate over HIV prevention efforts within drug treatment programs are further discussed in PART 4: PUBLIC POLICY ISSUES.

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