Drug Treatment Programs in Pennsylvania A Statewide Evaluation JOHN C. BALL, PhD HAROLD GRAFF, MD
A survey of all drug treatment programs in Pennsylvania was conducted to determine the prevalence of drug abuse in the state, the adequacy of treatment in various geographic areas, and the types of treatment available.
Introduction
public health viewpoint, it has usually not been possible to incidence or prevalence of drug dependency, calculate rates based on patients in treatment, or otherwise bring the topic within a comprehensive epidemiological measure
As the epidemic of drug abuse has continued to spread throughout the United States, it has become apparent that we are confronted with a major public health problem. Among the more significant reasons why drug dependency is increasingly being viewed as a public health problem are the following: (1) it is a communicable disease which is usually transmitted from person to person by social contact; (2) onset of drug dependency invariably is a voluntary act undertaken within a peer group setting at an early age; (3) spread of the disease follows quite definite epidemiological patterns; (4) both successful treatment and preventive measures require comprehensive community support and cooperation. Although each of these aspects of the drug dependency problem has been subjected to scientific scrutiny, we have been hampered in our investigation of the topic by a lack of comprehensive and inclusive data pertaining to sizable populations in definite geographic areas. In particular, there have been few statewide evaluations of drug abuse based upon representative samples from the general population or inclusive studies of patients in treatment.* Thus, from a Dr. Ball is Professor in the Department of Psychiatry, Temple University Health Sciences Center, Philadelphia, Pennsylvania. Dr. Graff is Director of the Division of Psychoanalytic Studies at the Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania. This research was supported in part by a contract from the Department of Welfare, Commonwealth of Pennsylvania. This article was accepted for publication in April, 1973. * For a comprehensive but early review of this topic see Reference 1. 592
AJPH JUNE, 1975, Vol. 65, No.6
framework.2 The present study was planned to provide information pertaining to all patients receiving treatment for drug abuse in the Commonwealth of Pennsylvania. In addition to obtaining these client data, the type and adequacy of treatment provided were subjected to direct investigation. The present Pennsylvania study constitutes the first comprehensive evaluation in the United States of all drug abuse programs within a state. Such a systematic approach has been advocated by both clinicians and researchers in their call for standards for systematic reporting of data pertaining to patients in treatment and for evaluation of results. From the standpoint of public health, the "state of the art" of drug abuse treatment needs to be clarified in order to determine what forms of treatment are available, what populations they serve, how they are supported, and whether or not they are effective. Community interest in providing treatment for drug abuse has widened to the point where many agencies-federal, state, local, and private-currently support programs. With multiple sources of support and direction, evaluation has been a difficult task due to differences in planning, ideology, treatment, and statistical reporting. This study of all programs within Pennsylvania constitutes the first attempt to bridge these differences. Several immediate benefits accrue from this approach. It is now possible, within a designated sociopolitical area, to analyze comparative rates of drug abusers in treatment; this
is an important first step in estimating incidence and prevalence of drug abuse. Further, it relates the availability of treatment to populations at risk. In sum, this approach measures the public response to a medical and social need. Specifically, the statewide field study was organized to ascertain: (1) the treatment point-prevalence of drug abuse within Pennsylvania; (2) the availability of treatment within Pennsylvania; (3) the history of program development; (4) what forms the treatment programs take. The objective of the research, then, was to delineate the scope of the problem, assay current attempts to deal with it, secure information as to the appropriateness of the treatment response, and finally, suggest improved methods of dealing with the drug problem.
The Field Survey Procedure A research team from Temple University Health Sciences Center conducted on-site visits to all 77 drug treatment programs in the state. The four members of the survey team consisted of two sociologists, one psychiatrist, and one social worker.* Each program was visited by at least two of the team members and many were seen by all four. The field work was undertaken during a 12-month period ending in May, 1972. The team traveled a total of 21,486 miles during the survey period. At each site the program director or other staff members were interviewed. A standardized interview schedule containing 60 items was employed to obtain consistent data from the programs. In addition, a complete tour of the facility was made and, as occasion dictated, particular aspects of the program were reviewed-medical care, patients' opinions and attitudes, records, administrative procedures, staffing patterns, community relations. The overall purpose of the on-site survey was to ascertain the number and type of drug treatment programs in the Commonwealth, describe the demographic characteristics of drug abusers, and obtain information as to the adequacy of the treatment provided. In sum, the purpose of the project was to provide a comprehensive delineation of "the state of the art" in Pennsylvania in 1972. Before discussing this, however, it is pertinent to trace briefly the historical development of drug abuse programs in the state.
History of Drug Abuse Treatment Most of the treatment programs for drug abusers in Pennsylvania are of recent origin.3 Indeed, of the 77 programs extant at the time of our field evaluation, all but three were established within the past 5 years. In 1967, when Winick and Bynder4 reported on 165 programs throughout the nation, they noted that Pennsylvania had a relatively low rate of drug use as compared to other states The team members were: John C. Ball, PhD, Freda Adler, PhD, Frederick B. Glaser, MD, and Arthur D. Moffett, MSW. *
(5.5 per 100,000
as compared to New York with 130 per 100,000). They noted the small number of programs in the group of states with such low rates. The recent history of drug abuse in Pennsylvania has been characterized by a marked rise in incidence accompanied by a parallel rise in the number of treatment programs. This reflects a public awareness of the problem but it also indicates a lack of long term planning. One benefit of a historical approach is to alert public health planners to the customary lag between onset of an epidemic and the societal response and to emphasize the need for cooperative statewide planning. The year in which each of the drug treatment programs was established is shown in Figure 1. The first program was begun in 1960 by the Pennsylvania Department of Probation and Parole; in this program, counseling and social service assistance were provided for Philadelphia offenders who were drug abusers or addicts. Thus, the earliest emphasis was upon compulsory rehabilitative services for hard-core opiate addicts. The next two drug treatment programs were established by Teen Challenge in the mid-1960s. These were residential therapeutic communities with a religious orientation. The Philadelphia Teen Challenge program began in 1964 and, a year later, the large residential farm facility was opened in Central Pennsylvania at Rehrersburg. It was not until 1968 that a major expansion of drug
treatment programs occurred. In that year, eight new programs were established; four of these were methadone maintenance facilities, two were residential therapeutic communities, one provided individual counseling for drug abusers, and one stressed group therapy. It seemed likely, then, as the number of treatment programs began to increase markedly, that quite diverse approaches to the treatment of drug abuse would be forthcoming in the years ahead. This expectation was fulfilled during the next 3 years as 60 new programs were established to provide a diversity of treatment and rehabilitative services for drug abusers in Pennsylvania. C1)
40r (5 0 2 30
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60 61 61 63 64 65 66 67 68 69 70 71
YEAR ESTABLISHED FIGURE 1 Drug treatment in Pennsylvania. 1972 is not included because of incomplete data. DRUG TREATMENT PROGRAMS
593
TABLE 1-Number of Drug Abusers in Treatment by Type of Program Treatment Modal ity
No. of Staff
No. of Patients
%of Patients
Methadone maintenance Residential therapeutic community Religious therapeutic community Nonresidential therapeutic community Detoxification Individual counseling Other modalities
17 13 7 8 2 19 11
213 147 125 116 42 82 54
2,816 624 175 265 33 908 757
50.5 11 2 3.1 4.8 0.6 16.3 13.6
Total
77
779
5,578
100.0
Major Modalities of Treatment Although both the number of drug treatment programs and the number of drug abusers receiving treatment in the Commonwealth continues to increase, it seemed likely (as of late 1972) that most, if not all, of the major modalities of treatment are amply represented in the 77 existing programss (Table 1).
Methadone Programs in Pennsylvania At the time of our field study, there were 17 methadone maintenance programs in Pennsylvania. The first four of these programs were established in 1968-two in Philadelphia, one in Pittsburgh, and one in Harrisburg. Following this beginning, methadone maintenance facilities have continued to expand. Not only have the number of programs increased considerably during the past 5 years, but the number of patients in these programs has markedly increased. Thus, with 50 per cent of the patients in treatment (2,816 of 5,578), methadone maintenance is the leading modality of treatment for drug abusers in Pennsylvania. Although there is considerable diversity in the number of patients enrolled in the 17 methadone programs, each of these clinics tends to treat more patients than do other modalities. Thus, eight of the 17 facilities had a patient census of 100 or more and two had over 500 outpatients. Indeed, these two programs-Black Action in Pittsburgh with 622 patients and the West Philadelphia Consortium with 877 patients-are the largest in the state.* The 17 methadone maintenance programs are medical in orientation and supervision. In eight programs, the director is a physician. In all programs, physicians are a part of the treatment staff, although this is usually on a part-time basis. In addition, most of the methadone clinics are located in hospitals or have special arrangements with hospitals to provide such services as physical examinations, laboratory tests, or "detoxification." A further, and perhaps paramount, reason for the medical orientation is that the dispensing of medication is the most frequent *
No. of
Programs
For an analysis of the largest treatment program in
Pennsylvania see Reference 6.
594 AJPH JUNE, 1975, Vol. 65, No.6
treatment activity and that is customarily done under medical supervision. Indeed, it would not be an exaggeration to say that the dispensation of methadone is the unifying process which permeates the entire program and which gives it a medical orientation.
Residential Therapeutic Communities The 13 residential therapeutic communities primarily treat the same population of heroin addicts as the methadone clinics. In the former modality, however, the treatment process is an intensive and continuing experience as residents are under continual and active supervision. Both behavior modification techniques and psychodynamic approaches are employed. Most of the staff members are ex-addicts; there is not only an absence of a professional staff, but such absence is often a matter of pride. These programs are characterized by a pervasive ideological commitment on the part of staff and patients.
Religious Therapeutic Communities Four of the seven religiously oriented residential treatment communities in Pennsylvania are affiliated with the national Teen Challenge Organization. The largest of these four is located on a productive farm in Berks County; the other three Teen Challenge Programs are in Philadelphia, Pittsburgh, and Harrisburg. The rehabilitation emphasis in these programs is upon the development of work skills and the acquisition of such basic educational capabilities as reading, writing, and ciphering.
Nonresidential Therapeutic Communities The ideological and behavioral orientation of these
drug treatment programs is similar to that of the residential therapeutic communities. Both are stringently anti-drug.
Both are primarily staffed by ex-addicts. Both foster close
in-group and moralistic attitudes. The nonresidential programs, however, demand less total compliance on the part
of members and are more involved in community affairs and problems. These programs also attract a larger proportion of middle class clients and fewer heroin addicts than their residential counterparts.
Detoxification We found a general lack of detoxification facilities for opiate abusers throughout the state. There were only two such detoxification programs with a total of 33 heroin addicts in treatment. Both of these were in Philadelphia area hospitals.
professional and ex-addict staff serve as leaders in the treatment process. The drop-in centers, or rap houses, cater mainly to young, middle class, "soft" drug users. In the social action program, participation in neighborhood projects was the primary means of rehabilitation employed. The multimodality facility was primarily a methadone maintenance clinic, although efforts were afoot to expand the range of treatment alternatives.
Individual Counseling Programs There were 19 programs for drug abusers in which individual counseling was the principal modality of treat-, ment. In these, therapy is done primarily by professionals (social workers, graduate students, psychologists, and occasionally psychiatrists) on a one-to-one basis. In addition, some of the programs have supervised group sessions. For the most part, the individual counseling centers resemble outpatient clinics, although the treatment atmosphere is more informal and peer-oriented. Most of the youthful clients are users of marijuana, amphetamines, barbiturates, or LSD rather than heroin.
Other Modalities of Treatment The remaining 11 programs included six in which outpatient group therapy was the focal point of treatment, three drop-in centers, one social action program, and one multimodality facility. In the group therapy programs, both
*ASHINGTON
GREEN
Characteristics of Drug Abusers There were 5,578 drug abusers in treatment within Pennsylvania at the time of our on-site evaluation of the 77 programs. In this section, the geographic distribution of these patients is analyzed and their social characteristics are
delineated. Attention is focused upon two questions: Where are the drug abusers located within the Commonwealth? And, who are the drug abusers?
Location within the Commonwealth
Drug abusers were receiving treatment in 24 of the 67 counties of Pennsylvania in 1972. Seventeen of these 24 counties (Figure 2) were metropolitan areas (classified as Standard Metropolitan Statistical Areas by the Census Bureau) and there was a marked concentration of patients in the two principal cities of the state-Philadelphia and Pittsburgh.
7
FAYETTE SSOMERSET
RATE OF DRUG ABUSERS IN TREATMENT PER 10,000 OF POPULATION 8.0 and above------High mm 7.9 to 3. I________Average 3.0 and be0low__-_-___Low E] 0.o_____-_____None in Treatmnent FIGURE 2 The treatment of drug abuse in Pennsylvania. DRUG TREATMENT PROGRAMS
595
Of the 5,578 drug abusers, 45.9 per cent were in Philadelphia County, 23.6 per cent were in Allegheny County, and the remaining 30.5 per cent were located in the other 22 counties shown in Figure 2. The impact of the two large metropolitan centers upon the prevalence of drug abuse is even more important than these figures indicate, as most of the drug abusers who are not in these two cities reside in adjacent or contiguous counties. Still, the fact that most of the counties below 100,000 population have no drug abusers in treatment, while most of those above 100,000 have drug abusers in treatment, suggests that population density as well as proximity to the two major cities are significant factors in the incidence of drug abuse. In considering the question of the metropolitan concentration of drug abusers, two further points are relevant. First, it is necessary to know that most of the drug abusers in treatment are local residents (96.0 per cent). Thus, there is little support for a "drift hypothesis" as an explanation of the concentration of drug abusers in large metropolitan areas.* Second, it is necessary to analyze rates of drug abusers in treatment if accurate scientific statements are to be made about the statewide distribution of the problem.2 Rates of Drug Abusers in Treatment
Rates of drug abusers in treatment were calculated for all 67 counties; the number of persons in treatment per 10,000 population was the procedure employed. The highest rates were obtained for Philadelphia and Allegheny Counties-13.2 and 8.2, respectively. The rate of drug abusers in treatment in Philadelphia is markedly higher than that of any other part of the state.
Sex and Race Differences Of the 5,578 patients in treatment, 4,415 were males and 1,163 were females. The male rate per 10,000 population for the state was 7.8; the female rate was 1.9. The males were, then, more than 4 times as likely to be receiving treatment for drug abuse than the females. The rate of drug abusers in treatment in Pennsylvania is 10 times higher for blacks than for whites. Of the 5,578 drug abusers, 44.8 per cent were black and 55.2 per cent were white. This may be compared with the 1970 racial composition of the state. Of the total population (11,804,324), 90.9 per cent is white and 9.1 per cent is black. As might be expected, the black patients were concentrated in Philadelphia and Allegheny Counties. As was not expected, however, the black rates (the number in treatment per 10,000 population) were high in 17 counties and the highest rates were not found in the two largest * The statement that most of those in treatment are local residents should not be interpreted as denying the importance of migrants or transients as transmitters of drug abuse patterns. In one community, we were informed that a sociometric analysis of drug abusers revealed that the heroin problem originated with the migration of fo4r addicts to the community from New York City."
596 AJPH JUNE, 1975, Vol. 65, No. 6
cities. A plausible interpretation of this unexpected finding is that drug abuse is a major problem in most black communities throughout the Commonwealth and, second, that the available treatment in both Philadelphia and Pittsburgh is inadequate. Support for this latter interpretation is provided by the long waiting lists we noted in these two cities.
Social Characteristics of the Drug Abusers It has been noted that the 5,578 drug abusers in treatment were located in 24 counties, concentrated in the two largest cities of the Commonwealth, and that the black population was overrepresented. In addition, drug abuse is primarily an indigenous problem in the sense that the vast majority of those receiving treatment are local residents. Of those in treatment, 96.0 per cent were Pennsylvania residents and most of these were from the same county in which they sought treatment. The drug abusers in treatment were a youthful population. Some 4.1 per cent were 17 years of age or younger, 34.4 per cent were between the ages of 18 and 20, and 58.6 per cent were 21 to 30 years of age; only 2.9 per cent were 30 years of age or older. The range in age of all patients in treatment was from 9 to 78 years. With respect to race, the black drug abusers were older than the white-most of those over 25 were black, while most of those under 21 were white. The youthfulness of the population in treatment is related to the early age at which onset of drug abuse commonly occurs. In Pennsylvania, as nationally, the onset of drug abuse is now an adolescent phenomenon. The research findings are remarkably consistent in showing that the years of highest risk are from 15 to 18.2 Most of the drug abusers in treatment were not gainfully employed, although the vast majority were in outpatient facilities. Some 59 per cent did not have steady employment, 12 per cent were attending public school or college, and only 29 per cent were employed (Table 2). These findings support the interpretation that persistent abuse of drugs is usually incompatible with steady employment or long term academic achievement. At the same time, it should be recognized that drug abusers commonly seek treatment only when compelled to do so by dint of circumstances-ill health, family disruption, fear of arrest, or lack of funds. As a consequence, those in TABLE 2-Employment Status of Drug Abusers
Drug Abusers Status
No.
%
Unemployed Employed Attending school Attending college
3,296 1,595 513 174
59.1 28.6 9.2 3.1
Total
5,578
100.0
treatment may appear to be more socially impaired than they were previously. Further evidence of the social inadequacy of these youthful drug abusers is provided by their economic dependence upon the state. Almost one-half (43.6 per cent) of the 5,578 drug abusers in treatment in Pennsylvania were recipients of public welfare. There is, then, an association between their current drug dependency and their economic dependency.
Type of Drug Abused At each of the 77 treatment programs visited, the principal drug abused by patients prior to admission was ascertained. In 54 of the programs, heroin was the main drug of abuse. In the other 23 programs, 12 reported that their patients were primarily polydrug abusers, five mentioned amphetamines, three marijuana, and one barbiturates. In addition to the principal drug of abuse, we asked at each program which other drugs were abused. The following drugs were mentioned: heroin, morphine, methadone, amphetamines, LSD, tranquilizers, barbiturates, marijuana, hashish, mescaline, cocaine, glue, solvent, and alcohol. A comparison of those programs in which heroin is the principal drug of abuse with the others reveals rather striking geographic and racial differences. Most of the polydrug abuse programs (using this term for all 23 of the nonheroin programs) were outside of Philadelphia and Allegheny Counties-17 of the 23 facilities. Conversely, 31 of the 54 programs in which heroin was the principal drug of abuse were located in these two metropolitan areas. Clearly, the heroin abusers are heavily concentrated in the two largest cities of the state, while the polydrug abusers are in the contiguous or outlying counties (Table 3). It is also significant that all 23 of the polydrug treatment programs included a majority of white patients. There was not a single polydrug abuse program in which black patients predominated. In all of the black programs, heroin was the principal drug of abuse prior to admission.
Patient and Staff Census of May, 1972
Inasmuch as most of the drug treatment programs were undergoing change or expansion at the time of our initial TABLE 3-Location of 77 Treatment Facilities by Type of Drug Abused
No. heroin
Philadelphia County Allegheny County Other counties
17 14
Total
Discussion In this field investigation, voluminous epidemiological and programmatic data were obtained. The major emphasis of this report is upon epidemiological findings, although these have been analyzed with respect to specific modalities of treatment. With regard to the programs themselves, it is pertinent in the present, phase I, context only to mention that we found an almost unbelievable variation in physical facilities, staffing patterns, medical service provided, equipment, administration, record-keeping procedures, and treatment ideologies. Phase I evaluation was planned as a comprehensive study of all drug abuse patients in Pennsylvania. Detailed program and client information was systematically obtained from all treatment facilities in the state. In this data collection procedure, the on-site visit by the research team was the keystone of this evaluation design. The next step in our evaluation schema, phase II, consists of three major undertakings: (1) establishment of a statewide communication network and data bank, (2) the development of program standards and regulations for the different modalities of treatment, and (3) the formulation of a statewide coordinating plan with provisions for technical, scientific, and medical assistance to all treatment programs within the state. The last stage in the evaluation schema, phase III, consists of comparative outcome studies of drug abuse treatment programs. Appropriate follow-up studies of former patients in the community constitutes an indispensable part of phase III.
Conclusion
Principal Drug of Abuse Location of Program
on-site visit, we decided to update our patient and staff census at the end of the field survey period. In response to special delivery and telephone requests, replies were received from 59 of the 77 programs by the end of May, 1972. From a tabulation of these reports, it was found that the numbers of patients in treatment had increased 37.3 per cent. There were 6,253 drug abusers receiving treatment in Pennsylvania. Similarly, the number of full-time staff at these 59 programs had increased by 29.1 per cent-from 671 to 866. On the basis of this May program census, then, it was evident that the rapid expansion of drug treatment programs was continuing in the state, although some caution should be exercised in accepting at face value unverified census data from drug abuse programs.*
No. other drugs
Total
-
23
6 17
17 20 40
54
23
77
A statewide study of drug abuse programs and the population of drug abusers in treatment has both scientific limitations and advantages. The major limitation of this * Although the validity of data obtained from narcotic addicts has been subjected to study, similar scientific investigation has not been undertaken with regard to programmatic data. With regard to the former studies, see References 8 and 9.
DRUG TREATMENT PROGRAMS 597
approach is that it is restricted to those who seek treatment and the representativeness of this population with respect to "true" incidence and prevalence in the state is unknown. The advantage of this approach is that it provides detailed infornation on a sizable portion of the statewide population of drug abusers and the treatment they receive. The data obtained through this field research procedure are more comprehensive and valid than those which have thus far been obtained through other procedures. The advice offered by Terry and Pellens' in 1928 is relevant to this epidemiological issue. They held that it was best to start by studying definite populations of known drug users.
References 1. Terry, C. E., and Pellens, M. The Opium Problem. Bureau of Social Hygiene, New York, 1928. 2. Ball, J. C., and Chambers, C. D. The Epidemiology of Opiate Addiction in the United States. Charles C Thomas, Springfield, IL, 1970.
3. Glaser, F. B., Ball, J. C., Moffett, A. D., and Adler, F. The Treatment of Narcotic Addiction in Philadelphia: Yesterday, Today and Tomorrow. Philadelphia Med. 67:613-621, 1971. 4. Winick, C., and Bynder, H. Facilities for Treatment and Rehabilitation of Narcotic Users and Addicts. Am. J. Public Health 57:1025-1033, 1967. 5. Glasscote, R., Sussex, J. N., Jaffe, J. H., Ball, J. C., and Brill, L. The Treatment of Drug Abuse. American Psychiatric Association, Washington, DC, 1972. 6. Ball, J. C., Moffett, A. D., Adler, F., and Glaser, F. B. The Patient, the Ex-Addict and the Professional View of Methadone Maintenance. Presented at the Annual Meeting of the American Association for the Advancement of Science, Philadelphia, Dec. 29, 1971. 7. Ball, J. C., and Bates, W. M. Migration and Residential Mobility of Narcotic Drug Addicts. Soc. Prob. 14:56-69, 1966. 8. Ball, J. C. The Reliability and Validity of Interview Data Obtained from 59 Narcotic Drug Addicts. Am. J. Sociol. 72:650-654, 1967. 9. Stephens, R. C. The Truthfulness of Addict Respondents in Research Projects. Int. J. Addict. 7:549-558, 1972.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
WANTED TO BE BETTER EXAMPLE AS A PARENT My initial experiment with smoking occurred during early high school years. The use of pipe and cigarettes continued through college and 3 years of graduate school, 4 years of college teaching, and 2 years of public health agency work. Mild upper respiratory difficulties became apparent. My cigarette use was less than one pack a day and pipe use probably less than 10 pipefuls a day. The conflict between my public health responsibilities and the example I was giving by smoking was obvious but did not induce me to stop. Television "antismoking" advertising was common at this time. One ad highlighted the inconsistency in a smoking parent advising his child not to smoke. This "hit home." As a parent to be, I resolved to stop smoking. One setback occurred with the birth of our first child-a difficult 24-hour labor for my wife. I started smoking again that night and it took almost a year to shake the habit again. Here again, however, my responsibility as a parent was the prime mover for me. I have found reaction to your "Thank you for not smoking" sign to be sometimes hostile, almost aggressive. Could this be because the sign emphasizes the discomfort to the other person? When I was smoking, it was easy to rationalize that if I wanted to take the risk to myself, that was my problem. Now more and more, the effects on nonsmokers are being emphasized. This forces the smoker into a highly defensive reaction. Mike Bouvier Owensboro, KY
598 AJPH JUNE, 1975, Vol. 65, No.6
A survey of all drug treatment programs in Pennsylvania was conducted to determine the prevalence of drug abuse in the state, the adequacy of treatment in various geographic areas, and the types of treatment available.
Introduction
public health viewpoint, it has usually not been possible to incidence or prevalence of drug dependency, calculate rates based on patients in treatment, or otherwise bring the topic within a comprehensive epidemiological measure
As the epidemic of drug abuse has continued to spread throughout the United States, it has become apparent that we are confronted with a major public health problem. Among the more significant reasons why drug dependency is increasingly being viewed as a public health problem are the following: (1) it is a communicable disease which is usually transmitted from person to person by social contact; (2) onset of drug dependency invariably is a voluntary act undertaken within a peer group setting at an early age; (3) spread of the disease follows quite definite epidemiological patterns; (4) both successful treatment and preventive measures require comprehensive community support and cooperation. Although each of these aspects of the drug dependency problem has been subjected to scientific scrutiny, we have been hampered in our investigation of the topic by a lack of comprehensive and inclusive data pertaining to sizable populations in definite geographic areas. In particular, there have been few statewide evaluations of drug abuse based upon representative samples from the general population or inclusive studies of patients in treatment.* Thus, from a Dr. Ball is Professor in the Department of Psychiatry, Temple University Health Sciences Center, Philadelphia, Pennsylvania. Dr. Graff is Director of the Division of Psychoanalytic Studies at the Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania. This research was supported in part by a contract from the Department of Welfare, Commonwealth of Pennsylvania. This article was accepted for publication in April, 1973. * For a comprehensive but early review of this topic see Reference 1. 592
AJPH JUNE, 1975, Vol. 65, No.6
framework.2 The present study was planned to provide information pertaining to all patients receiving treatment for drug abuse in the Commonwealth of Pennsylvania. In addition to obtaining these client data, the type and adequacy of treatment provided were subjected to direct investigation. The present Pennsylvania study constitutes the first comprehensive evaluation in the United States of all drug abuse programs within a state. Such a systematic approach has been advocated by both clinicians and researchers in their call for standards for systematic reporting of data pertaining to patients in treatment and for evaluation of results. From the standpoint of public health, the "state of the art" of drug abuse treatment needs to be clarified in order to determine what forms of treatment are available, what populations they serve, how they are supported, and whether or not they are effective. Community interest in providing treatment for drug abuse has widened to the point where many agencies-federal, state, local, and private-currently support programs. With multiple sources of support and direction, evaluation has been a difficult task due to differences in planning, ideology, treatment, and statistical reporting. This study of all programs within Pennsylvania constitutes the first attempt to bridge these differences. Several immediate benefits accrue from this approach. It is now possible, within a designated sociopolitical area, to analyze comparative rates of drug abusers in treatment; this
is an important first step in estimating incidence and prevalence of drug abuse. Further, it relates the availability of treatment to populations at risk. In sum, this approach measures the public response to a medical and social need. Specifically, the statewide field study was organized to ascertain: (1) the treatment point-prevalence of drug abuse within Pennsylvania; (2) the availability of treatment within Pennsylvania; (3) the history of program development; (4) what forms the treatment programs take. The objective of the research, then, was to delineate the scope of the problem, assay current attempts to deal with it, secure information as to the appropriateness of the treatment response, and finally, suggest improved methods of dealing with the drug problem.
The Field Survey Procedure A research team from Temple University Health Sciences Center conducted on-site visits to all 77 drug treatment programs in the state. The four members of the survey team consisted of two sociologists, one psychiatrist, and one social worker.* Each program was visited by at least two of the team members and many were seen by all four. The field work was undertaken during a 12-month period ending in May, 1972. The team traveled a total of 21,486 miles during the survey period. At each site the program director or other staff members were interviewed. A standardized interview schedule containing 60 items was employed to obtain consistent data from the programs. In addition, a complete tour of the facility was made and, as occasion dictated, particular aspects of the program were reviewed-medical care, patients' opinions and attitudes, records, administrative procedures, staffing patterns, community relations. The overall purpose of the on-site survey was to ascertain the number and type of drug treatment programs in the Commonwealth, describe the demographic characteristics of drug abusers, and obtain information as to the adequacy of the treatment provided. In sum, the purpose of the project was to provide a comprehensive delineation of "the state of the art" in Pennsylvania in 1972. Before discussing this, however, it is pertinent to trace briefly the historical development of drug abuse programs in the state.
History of Drug Abuse Treatment Most of the treatment programs for drug abusers in Pennsylvania are of recent origin.3 Indeed, of the 77 programs extant at the time of our field evaluation, all but three were established within the past 5 years. In 1967, when Winick and Bynder4 reported on 165 programs throughout the nation, they noted that Pennsylvania had a relatively low rate of drug use as compared to other states The team members were: John C. Ball, PhD, Freda Adler, PhD, Frederick B. Glaser, MD, and Arthur D. Moffett, MSW. *
(5.5 per 100,000
as compared to New York with 130 per 100,000). They noted the small number of programs in the group of states with such low rates. The recent history of drug abuse in Pennsylvania has been characterized by a marked rise in incidence accompanied by a parallel rise in the number of treatment programs. This reflects a public awareness of the problem but it also indicates a lack of long term planning. One benefit of a historical approach is to alert public health planners to the customary lag between onset of an epidemic and the societal response and to emphasize the need for cooperative statewide planning. The year in which each of the drug treatment programs was established is shown in Figure 1. The first program was begun in 1960 by the Pennsylvania Department of Probation and Parole; in this program, counseling and social service assistance were provided for Philadelphia offenders who were drug abusers or addicts. Thus, the earliest emphasis was upon compulsory rehabilitative services for hard-core opiate addicts. The next two drug treatment programs were established by Teen Challenge in the mid-1960s. These were residential therapeutic communities with a religious orientation. The Philadelphia Teen Challenge program began in 1964 and, a year later, the large residential farm facility was opened in Central Pennsylvania at Rehrersburg. It was not until 1968 that a major expansion of drug
treatment programs occurred. In that year, eight new programs were established; four of these were methadone maintenance facilities, two were residential therapeutic communities, one provided individual counseling for drug abusers, and one stressed group therapy. It seemed likely, then, as the number of treatment programs began to increase markedly, that quite diverse approaches to the treatment of drug abuse would be forthcoming in the years ahead. This expectation was fulfilled during the next 3 years as 60 new programs were established to provide a diversity of treatment and rehabilitative services for drug abusers in Pennsylvania. C1)
40r (5 0 2 30
0r
36
-
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61 LL aJ
:D
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10 o o o
000_
0
_
o o 0
-
60 61 61 63 64 65 66 67 68 69 70 71
YEAR ESTABLISHED FIGURE 1 Drug treatment in Pennsylvania. 1972 is not included because of incomplete data. DRUG TREATMENT PROGRAMS
593
TABLE 1-Number of Drug Abusers in Treatment by Type of Program Treatment Modal ity
No. of Staff
No. of Patients
%of Patients
Methadone maintenance Residential therapeutic community Religious therapeutic community Nonresidential therapeutic community Detoxification Individual counseling Other modalities
17 13 7 8 2 19 11
213 147 125 116 42 82 54
2,816 624 175 265 33 908 757
50.5 11 2 3.1 4.8 0.6 16.3 13.6
Total
77
779
5,578
100.0
Major Modalities of Treatment Although both the number of drug treatment programs and the number of drug abusers receiving treatment in the Commonwealth continues to increase, it seemed likely (as of late 1972) that most, if not all, of the major modalities of treatment are amply represented in the 77 existing programss (Table 1).
Methadone Programs in Pennsylvania At the time of our field study, there were 17 methadone maintenance programs in Pennsylvania. The first four of these programs were established in 1968-two in Philadelphia, one in Pittsburgh, and one in Harrisburg. Following this beginning, methadone maintenance facilities have continued to expand. Not only have the number of programs increased considerably during the past 5 years, but the number of patients in these programs has markedly increased. Thus, with 50 per cent of the patients in treatment (2,816 of 5,578), methadone maintenance is the leading modality of treatment for drug abusers in Pennsylvania. Although there is considerable diversity in the number of patients enrolled in the 17 methadone programs, each of these clinics tends to treat more patients than do other modalities. Thus, eight of the 17 facilities had a patient census of 100 or more and two had over 500 outpatients. Indeed, these two programs-Black Action in Pittsburgh with 622 patients and the West Philadelphia Consortium with 877 patients-are the largest in the state.* The 17 methadone maintenance programs are medical in orientation and supervision. In eight programs, the director is a physician. In all programs, physicians are a part of the treatment staff, although this is usually on a part-time basis. In addition, most of the methadone clinics are located in hospitals or have special arrangements with hospitals to provide such services as physical examinations, laboratory tests, or "detoxification." A further, and perhaps paramount, reason for the medical orientation is that the dispensing of medication is the most frequent *
No. of
Programs
For an analysis of the largest treatment program in
Pennsylvania see Reference 6.
594 AJPH JUNE, 1975, Vol. 65, No.6
treatment activity and that is customarily done under medical supervision. Indeed, it would not be an exaggeration to say that the dispensation of methadone is the unifying process which permeates the entire program and which gives it a medical orientation.
Residential Therapeutic Communities The 13 residential therapeutic communities primarily treat the same population of heroin addicts as the methadone clinics. In the former modality, however, the treatment process is an intensive and continuing experience as residents are under continual and active supervision. Both behavior modification techniques and psychodynamic approaches are employed. Most of the staff members are ex-addicts; there is not only an absence of a professional staff, but such absence is often a matter of pride. These programs are characterized by a pervasive ideological commitment on the part of staff and patients.
Religious Therapeutic Communities Four of the seven religiously oriented residential treatment communities in Pennsylvania are affiliated with the national Teen Challenge Organization. The largest of these four is located on a productive farm in Berks County; the other three Teen Challenge Programs are in Philadelphia, Pittsburgh, and Harrisburg. The rehabilitation emphasis in these programs is upon the development of work skills and the acquisition of such basic educational capabilities as reading, writing, and ciphering.
Nonresidential Therapeutic Communities The ideological and behavioral orientation of these
drug treatment programs is similar to that of the residential therapeutic communities. Both are stringently anti-drug.
Both are primarily staffed by ex-addicts. Both foster close
in-group and moralistic attitudes. The nonresidential programs, however, demand less total compliance on the part
of members and are more involved in community affairs and problems. These programs also attract a larger proportion of middle class clients and fewer heroin addicts than their residential counterparts.
Detoxification We found a general lack of detoxification facilities for opiate abusers throughout the state. There were only two such detoxification programs with a total of 33 heroin addicts in treatment. Both of these were in Philadelphia area hospitals.
professional and ex-addict staff serve as leaders in the treatment process. The drop-in centers, or rap houses, cater mainly to young, middle class, "soft" drug users. In the social action program, participation in neighborhood projects was the primary means of rehabilitation employed. The multimodality facility was primarily a methadone maintenance clinic, although efforts were afoot to expand the range of treatment alternatives.
Individual Counseling Programs There were 19 programs for drug abusers in which individual counseling was the principal modality of treat-, ment. In these, therapy is done primarily by professionals (social workers, graduate students, psychologists, and occasionally psychiatrists) on a one-to-one basis. In addition, some of the programs have supervised group sessions. For the most part, the individual counseling centers resemble outpatient clinics, although the treatment atmosphere is more informal and peer-oriented. Most of the youthful clients are users of marijuana, amphetamines, barbiturates, or LSD rather than heroin.
Other Modalities of Treatment The remaining 11 programs included six in which outpatient group therapy was the focal point of treatment, three drop-in centers, one social action program, and one multimodality facility. In the group therapy programs, both
*ASHINGTON
GREEN
Characteristics of Drug Abusers There were 5,578 drug abusers in treatment within Pennsylvania at the time of our on-site evaluation of the 77 programs. In this section, the geographic distribution of these patients is analyzed and their social characteristics are
delineated. Attention is focused upon two questions: Where are the drug abusers located within the Commonwealth? And, who are the drug abusers?
Location within the Commonwealth
Drug abusers were receiving treatment in 24 of the 67 counties of Pennsylvania in 1972. Seventeen of these 24 counties (Figure 2) were metropolitan areas (classified as Standard Metropolitan Statistical Areas by the Census Bureau) and there was a marked concentration of patients in the two principal cities of the state-Philadelphia and Pittsburgh.
7
FAYETTE SSOMERSET
RATE OF DRUG ABUSERS IN TREATMENT PER 10,000 OF POPULATION 8.0 and above------High mm 7.9 to 3. I________Average 3.0 and be0low__-_-___Low E] 0.o_____-_____None in Treatmnent FIGURE 2 The treatment of drug abuse in Pennsylvania. DRUG TREATMENT PROGRAMS
595
Of the 5,578 drug abusers, 45.9 per cent were in Philadelphia County, 23.6 per cent were in Allegheny County, and the remaining 30.5 per cent were located in the other 22 counties shown in Figure 2. The impact of the two large metropolitan centers upon the prevalence of drug abuse is even more important than these figures indicate, as most of the drug abusers who are not in these two cities reside in adjacent or contiguous counties. Still, the fact that most of the counties below 100,000 population have no drug abusers in treatment, while most of those above 100,000 have drug abusers in treatment, suggests that population density as well as proximity to the two major cities are significant factors in the incidence of drug abuse. In considering the question of the metropolitan concentration of drug abusers, two further points are relevant. First, it is necessary to know that most of the drug abusers in treatment are local residents (96.0 per cent). Thus, there is little support for a "drift hypothesis" as an explanation of the concentration of drug abusers in large metropolitan areas.* Second, it is necessary to analyze rates of drug abusers in treatment if accurate scientific statements are to be made about the statewide distribution of the problem.2 Rates of Drug Abusers in Treatment
Rates of drug abusers in treatment were calculated for all 67 counties; the number of persons in treatment per 10,000 population was the procedure employed. The highest rates were obtained for Philadelphia and Allegheny Counties-13.2 and 8.2, respectively. The rate of drug abusers in treatment in Philadelphia is markedly higher than that of any other part of the state.
Sex and Race Differences Of the 5,578 patients in treatment, 4,415 were males and 1,163 were females. The male rate per 10,000 population for the state was 7.8; the female rate was 1.9. The males were, then, more than 4 times as likely to be receiving treatment for drug abuse than the females. The rate of drug abusers in treatment in Pennsylvania is 10 times higher for blacks than for whites. Of the 5,578 drug abusers, 44.8 per cent were black and 55.2 per cent were white. This may be compared with the 1970 racial composition of the state. Of the total population (11,804,324), 90.9 per cent is white and 9.1 per cent is black. As might be expected, the black patients were concentrated in Philadelphia and Allegheny Counties. As was not expected, however, the black rates (the number in treatment per 10,000 population) were high in 17 counties and the highest rates were not found in the two largest * The statement that most of those in treatment are local residents should not be interpreted as denying the importance of migrants or transients as transmitters of drug abuse patterns. In one community, we were informed that a sociometric analysis of drug abusers revealed that the heroin problem originated with the migration of fo4r addicts to the community from New York City."
596 AJPH JUNE, 1975, Vol. 65, No. 6
cities. A plausible interpretation of this unexpected finding is that drug abuse is a major problem in most black communities throughout the Commonwealth and, second, that the available treatment in both Philadelphia and Pittsburgh is inadequate. Support for this latter interpretation is provided by the long waiting lists we noted in these two cities.
Social Characteristics of the Drug Abusers It has been noted that the 5,578 drug abusers in treatment were located in 24 counties, concentrated in the two largest cities of the Commonwealth, and that the black population was overrepresented. In addition, drug abuse is primarily an indigenous problem in the sense that the vast majority of those receiving treatment are local residents. Of those in treatment, 96.0 per cent were Pennsylvania residents and most of these were from the same county in which they sought treatment. The drug abusers in treatment were a youthful population. Some 4.1 per cent were 17 years of age or younger, 34.4 per cent were between the ages of 18 and 20, and 58.6 per cent were 21 to 30 years of age; only 2.9 per cent were 30 years of age or older. The range in age of all patients in treatment was from 9 to 78 years. With respect to race, the black drug abusers were older than the white-most of those over 25 were black, while most of those under 21 were white. The youthfulness of the population in treatment is related to the early age at which onset of drug abuse commonly occurs. In Pennsylvania, as nationally, the onset of drug abuse is now an adolescent phenomenon. The research findings are remarkably consistent in showing that the years of highest risk are from 15 to 18.2 Most of the drug abusers in treatment were not gainfully employed, although the vast majority were in outpatient facilities. Some 59 per cent did not have steady employment, 12 per cent were attending public school or college, and only 29 per cent were employed (Table 2). These findings support the interpretation that persistent abuse of drugs is usually incompatible with steady employment or long term academic achievement. At the same time, it should be recognized that drug abusers commonly seek treatment only when compelled to do so by dint of circumstances-ill health, family disruption, fear of arrest, or lack of funds. As a consequence, those in TABLE 2-Employment Status of Drug Abusers
Drug Abusers Status
No.
%
Unemployed Employed Attending school Attending college
3,296 1,595 513 174
59.1 28.6 9.2 3.1
Total
5,578
100.0
treatment may appear to be more socially impaired than they were previously. Further evidence of the social inadequacy of these youthful drug abusers is provided by their economic dependence upon the state. Almost one-half (43.6 per cent) of the 5,578 drug abusers in treatment in Pennsylvania were recipients of public welfare. There is, then, an association between their current drug dependency and their economic dependency.
Type of Drug Abused At each of the 77 treatment programs visited, the principal drug abused by patients prior to admission was ascertained. In 54 of the programs, heroin was the main drug of abuse. In the other 23 programs, 12 reported that their patients were primarily polydrug abusers, five mentioned amphetamines, three marijuana, and one barbiturates. In addition to the principal drug of abuse, we asked at each program which other drugs were abused. The following drugs were mentioned: heroin, morphine, methadone, amphetamines, LSD, tranquilizers, barbiturates, marijuana, hashish, mescaline, cocaine, glue, solvent, and alcohol. A comparison of those programs in which heroin is the principal drug of abuse with the others reveals rather striking geographic and racial differences. Most of the polydrug abuse programs (using this term for all 23 of the nonheroin programs) were outside of Philadelphia and Allegheny Counties-17 of the 23 facilities. Conversely, 31 of the 54 programs in which heroin was the principal drug of abuse were located in these two metropolitan areas. Clearly, the heroin abusers are heavily concentrated in the two largest cities of the state, while the polydrug abusers are in the contiguous or outlying counties (Table 3). It is also significant that all 23 of the polydrug treatment programs included a majority of white patients. There was not a single polydrug abuse program in which black patients predominated. In all of the black programs, heroin was the principal drug of abuse prior to admission.
Patient and Staff Census of May, 1972
Inasmuch as most of the drug treatment programs were undergoing change or expansion at the time of our initial TABLE 3-Location of 77 Treatment Facilities by Type of Drug Abused
No. heroin
Philadelphia County Allegheny County Other counties
17 14
Total
Discussion In this field investigation, voluminous epidemiological and programmatic data were obtained. The major emphasis of this report is upon epidemiological findings, although these have been analyzed with respect to specific modalities of treatment. With regard to the programs themselves, it is pertinent in the present, phase I, context only to mention that we found an almost unbelievable variation in physical facilities, staffing patterns, medical service provided, equipment, administration, record-keeping procedures, and treatment ideologies. Phase I evaluation was planned as a comprehensive study of all drug abuse patients in Pennsylvania. Detailed program and client information was systematically obtained from all treatment facilities in the state. In this data collection procedure, the on-site visit by the research team was the keystone of this evaluation design. The next step in our evaluation schema, phase II, consists of three major undertakings: (1) establishment of a statewide communication network and data bank, (2) the development of program standards and regulations for the different modalities of treatment, and (3) the formulation of a statewide coordinating plan with provisions for technical, scientific, and medical assistance to all treatment programs within the state. The last stage in the evaluation schema, phase III, consists of comparative outcome studies of drug abuse treatment programs. Appropriate follow-up studies of former patients in the community constitutes an indispensable part of phase III.
Conclusion
Principal Drug of Abuse Location of Program
on-site visit, we decided to update our patient and staff census at the end of the field survey period. In response to special delivery and telephone requests, replies were received from 59 of the 77 programs by the end of May, 1972. From a tabulation of these reports, it was found that the numbers of patients in treatment had increased 37.3 per cent. There were 6,253 drug abusers receiving treatment in Pennsylvania. Similarly, the number of full-time staff at these 59 programs had increased by 29.1 per cent-from 671 to 866. On the basis of this May program census, then, it was evident that the rapid expansion of drug treatment programs was continuing in the state, although some caution should be exercised in accepting at face value unverified census data from drug abuse programs.*
No. other drugs
Total
-
23
6 17
17 20 40
54
23
77
A statewide study of drug abuse programs and the population of drug abusers in treatment has both scientific limitations and advantages. The major limitation of this * Although the validity of data obtained from narcotic addicts has been subjected to study, similar scientific investigation has not been undertaken with regard to programmatic data. With regard to the former studies, see References 8 and 9.
DRUG TREATMENT PROGRAMS 597
approach is that it is restricted to those who seek treatment and the representativeness of this population with respect to "true" incidence and prevalence in the state is unknown. The advantage of this approach is that it provides detailed infornation on a sizable portion of the statewide population of drug abusers and the treatment they receive. The data obtained through this field research procedure are more comprehensive and valid than those which have thus far been obtained through other procedures. The advice offered by Terry and Pellens' in 1928 is relevant to this epidemiological issue. They held that it was best to start by studying definite populations of known drug users.
References 1. Terry, C. E., and Pellens, M. The Opium Problem. Bureau of Social Hygiene, New York, 1928. 2. Ball, J. C., and Chambers, C. D. The Epidemiology of Opiate Addiction in the United States. Charles C Thomas, Springfield, IL, 1970.
3. Glaser, F. B., Ball, J. C., Moffett, A. D., and Adler, F. The Treatment of Narcotic Addiction in Philadelphia: Yesterday, Today and Tomorrow. Philadelphia Med. 67:613-621, 1971. 4. Winick, C., and Bynder, H. Facilities for Treatment and Rehabilitation of Narcotic Users and Addicts. Am. J. Public Health 57:1025-1033, 1967. 5. Glasscote, R., Sussex, J. N., Jaffe, J. H., Ball, J. C., and Brill, L. The Treatment of Drug Abuse. American Psychiatric Association, Washington, DC, 1972. 6. Ball, J. C., Moffett, A. D., Adler, F., and Glaser, F. B. The Patient, the Ex-Addict and the Professional View of Methadone Maintenance. Presented at the Annual Meeting of the American Association for the Advancement of Science, Philadelphia, Dec. 29, 1971. 7. Ball, J. C., and Bates, W. M. Migration and Residential Mobility of Narcotic Drug Addicts. Soc. Prob. 14:56-69, 1966. 8. Ball, J. C. The Reliability and Validity of Interview Data Obtained from 59 Narcotic Drug Addicts. Am. J. Sociol. 72:650-654, 1967. 9. Stephens, R. C. The Truthfulness of Addict Respondents in Research Projects. Int. J. Addict. 7:549-558, 1972.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
WANTED TO BE BETTER EXAMPLE AS A PARENT My initial experiment with smoking occurred during early high school years. The use of pipe and cigarettes continued through college and 3 years of graduate school, 4 years of college teaching, and 2 years of public health agency work. Mild upper respiratory difficulties became apparent. My cigarette use was less than one pack a day and pipe use probably less than 10 pipefuls a day. The conflict between my public health responsibilities and the example I was giving by smoking was obvious but did not induce me to stop. Television "antismoking" advertising was common at this time. One ad highlighted the inconsistency in a smoking parent advising his child not to smoke. This "hit home." As a parent to be, I resolved to stop smoking. One setback occurred with the birth of our first child-a difficult 24-hour labor for my wife. I started smoking again that night and it took almost a year to shake the habit again. Here again, however, my responsibility as a parent was the prime mover for me. I have found reaction to your "Thank you for not smoking" sign to be sometimes hostile, almost aggressive. Could this be because the sign emphasizes the discomfort to the other person? When I was smoking, it was easy to rationalize that if I wanted to take the risk to myself, that was my problem. Now more and more, the effects on nonsmokers are being emphasized. This forces the smoker into a highly defensive reaction. Mike Bouvier Owensboro, KY
598 AJPH JUNE, 1975, Vol. 65, No.6
