Treating Substance Abuse in the Community: A Haight Ashbury Free Clinics'
Perspective
by David E. Smith, MD and Richard B. Seymour, MA
July 1998
In keeping with the maxim "think globally, act locally," addiction
and substance abuse must be seen as problems that call for world-wide strategies
and interactions, but must be addressed within the community. The recent
formation of the International Society of Addiction Medicine (ISAM), based on
the American Society of Addiction Medicine (ASAM) and similar addiction medicine
societies in other countries, is a step toward forming world-wide strategies.
The adoption of the International Addictions Infoline, edited by Richard B.
Seymour and published by the Haight Ashbury Free Clinics, Inc., (HAFCI), places
our San Francisco community in the forefront of developing world-wide strategies
for treating addiction and substance abuse.
Treatment delivery needs to be a community effort. For the last 31 years at
the Haight Ashbury Free Clinics, this has meant responding to each new drug
problem as it appeared within the community, often developing protocols for
treating new drugs and drug combinations when they appear. It has also meant
paying attention to national and international trends in abuse, and working with
other epidemiological sources to compile data and develop forecasts of future
trends, such as the ongoing upper/downer cycle of abuse.
Since the 1960s, Dr. John Newmeyer and other researchers at HAFCI have
charted an ongoing cycle of upper and downer abuse with an approximate 10-year
duration for each side of the cycle. At present, we are emerging from a cycle of
increased cocaine and methamphetamine abuse but entering a period of increased
heroin and other downer drug abuse. According to a very recent report in the San
Francisco Examiner, San Francisco now has twice the rate of drug-related
deaths as the rest of California. Higher purity and lower cost heroin have been
cited by health officials as the leading cause of drug deaths here. As Dr.
Newmeyer pointed out at the time, "speed kills—but not as much as
heroin."
A major impediment to dealing with drug impairment and mortality has been the
lack of available treatment for all who need it. At any given time, half the
drug addicts and abusers who seek treatment in San Francisco are put on waiting
lists. This is a tragedy in that drug treatment must take advantage of any
window of opportunity when users seek it. Otherwise they may never seek
treatment and may die of their disease. As it did with the AIDS epidemic, San
Francisco is responding with a multi-agency effort, in this case by developing a
Treatment on Demand program. With the strong support it has at state and
national levels, this may soon make San Francisco the first city in the United
States where drug treatment is available for all who need it, when they need it.
While quantity of care is important, quality of care is equally if not more
important. Addiction is a pernicious disease, and its treatment calls for
constant refining of protocols and an ongoing search for more effective medical
and psycho-social tools. Statistical research can tell the field certain
quantifiable things about trends, but it doesn't provide the whole answer.
HAFCI, working with a network of substance abuse treatment colleagues from
throughout the United States and overseas, is engaged in clinical research on
new medical/psycho-social approaches to abuse and in developing qualitative
research techniques so that more can be learned about why people use the
drugs they use—the better to direct their treatment.
Drug patterns in San Francisco, and throughout the world, tend to be complex
and dependent on a number of factors, such as drug availability, public and
sub-group opinion, desired results, dynamics of abuse, etc. For example, one
factor in the upper/downer cycle is that both upper and downer drugs produce
increasingly unpleasant side effects over time. To relieve these, users will
employ drugs with opposing effects to counteract these side effects, such as
cocaine for heroin and vice versa. Eventually, the users may decide that the
counteractive drug is better. They are bored with their drug of choice or tired
of hassling with the side effects, and the cycle takes another turn.
Within and around the larger cycles, other drug trends are taking place.
These may be the result of new drugs appearing on the scene, such as
phencyclidine (PCP) in the late 1970s and methylenedioxymethamphetamine (MDMA)
in the 1980s, or emerging patterns of abuse, such as the date-rape phenomena
involving a variety of old and new drugs, including gamma-hydroxybutyrate (GHB)
and the abuse of anabolic steroids for athletic performance and body-image. Drug
abuse can also be economically driven. Emergence of new supply networks,
providing easier access to higher-potency products can profoundly effect use
patterns. Darryl Inaba, Pharm.D., director of HAFCI's outpatient drug treatment
programs, has pointed out that drug patterns can vary from neighborhood to
neighborhood, depending on who is in control of the street market.
The current paradigm of addiction, recognized by HAFCI and accepted in
general by the addiction treatment community, is that addiction is a primary
disease, characterized by compulsion, loss of control and continued use in spite
of adverse consequences. It is progressive, incurable and potentially fatal if
not treated. Addiction is considered to be "incurable" in that once an
individual has crossed the line and lost control, there is no possibility of
returning to controlled use. Addiction can, however, be brought into remission
through abstinence and adopting a program of supported recovery, such as that
offered by the various 12-step fellowships. In light of this paradigm, the role
of treatment is that of providing a bridge from active addiction to active
recovery.
There is a great deal of evidence that addiction treatment is effective and
saves society a great deal of money. A treatment outcome study conducted by the
California State Substance Abuse Services, referred to as the CalData Study,
indicated that every dollar spent in treatment saves the community seven dollars
in health and social costs. It has also been determined that 80% of people in
the criminal justice system have substance abuse problems, but only 5% receive
treatment there. Diversion to treatment via the drug court has been a
cost-effective approach to both rehabilitation and crime reduction. Diagnosis
driven treatment using the ASAM patient criteria may dictate treatment
modalities ranging from methadone maintenance through therapeutic communities to
detoxification and drug-free 12-step recovery as emphasized by HAFCI. "One
size does not fit all," and treatment must be matched to the needs of the
patient, as with any chronic disease. However, it has been proven that the
addict in treatment does better than the addict not in treatment.
Levels of service in the Patient Placement Criteria range from early
intervention through outpatient services to medically-managed intensive
inpatient care. Primary problem areas evaluated in developing a placement are:
(1) acute intoxication and/or withdrawal potential; (2) biomedical conditions
and complications; (3) emotional/behavioral conditions and complications; (4)
treatment acceptance/resistance; (5) relapse/continued use potential; and (6)
recovery/living environment. The prognosis for resolution of these problems
depends on the clinician's knowledge of problem severity and the level of
difficulty of resolution.
While the eventual process of recovery may be similar for most individuals,
treatment initiation for overdose, detoxification and aftercare within combined
medical and psycho-social programs, such as those offered by HAFCI, is usually
drug-specific. Opioid overdose treatment may call for a short-acting opioid
antagonist, such as naloxone (Narcan®) and a mix of medication to relieve the
symptoms of withdrawal. Sedative-hypnotic treatment, including that for alcohol
addiction, may involve hospitalization and substitution of a slow-acting drug,
such as phenobarbitol, in order to avoid life-threatening seizures. Other drugs
call for other interventions, and there is a continuing need for research to
develop new and more effective treatment protocols.
One promising area for treatment is the development of anti-craving agents to
prevent relapse into active addiction. For example, naltrexone (Revia®), a
long-acting opioid antagonist that has been in use for opioid addict aftercare
and as an aid to blocking the effects of opioids and thereby warding off
possible relapses, has been found effective in decreasing alcohol craving in
recovering alcoholics. In general, research on the interaction between drugs and
brain transmitter/receptor mechanisms is opening many new avenues for treatment,
such as the development of specific drug antagonists for cocaine and
benzodiazepines. Further, a variety of new treatment medicines are under
development and have been approved for human clinical trials with drug abuse
client populations. In keeping with its history of pioneering treatment efforts,
HAFCI's clinical research team headed by Gantt P. Galloway, Pharm.D., is
conducting clinical trials for new medications to treat cocaine addiction and
other specific addictions.
Today, Haight Ashbury Free Clinics, Inc., (HAFCI) has 22 treatment sites in
San Francisco and environs. These provide a variety of services including
primary medical care through the Haight Ashbury Free Medical Clinic. HAFCI
continues to provide treatment for a full range of drug abuse and addiction
problems. Besides treatment and research, HAFCI presents training in the form of
continuing medical education programs. These include periodic one- or two-day
seminars on specific topics and an annual conference. For more information on
HAFCI's training activities and to get on the mailing list for future
conferences, contact Chantelle Engle at (415) 487-3658.
HAFCI is one of the few treatment entities that provides mental health and
HIV/AIDS treatment for its drug patients. In general, the scope of treatment
provided by the clinics requires the services of staff and volunteers with a
wide range of talents and expertise. As a result, the various treatment centers
are often in need of skilled volunteers, including physicians, nurses, nurse
practitioners, counselors of all varieties and individuals to answer phones and
help maintain many different services. Past volunteers have found their exposure
to the clinics' multitude of treatment situations an invaluable experience.
Individuals who are interested in volunteering or seeking more information about
the clinics should call the central office at (415) 561-5200.
Throughout its 31-year history, HAFCI has provided its services to the
community "free at the point of delivery." Many of the clinics'
patients are homeless or among the working poor who have neither health
insurance nor the wherewithal to provide for their own care. However, as a point
of human dignity, individuals should not have to document their poverty in order
to receive the quality health care that is their right. Although the clinics do
have grants and treatment contracts supporting facets of their work, these are
never enough. HAFCI depends on donations to continue providing needed treatment
within the community. Donations can include both money and materials. Each
clinic has a wish list of things it needs, including computers, household items,
clothing for residential patients, toys, blankets and many more. Today, as in
1967, love needs care—and care needs help. If you can help, please call the
Haight Ashbury Free Clinics Development Office at (415) 561-5252.
David Smith, MD is founder, president and medical director of the Haight
Ashbury Free Clinic, Inc. He is also past president of the American Society of
Addiction Medicine and associate clinical professor at UCSF.
Richard Seymour, MA, is information and education director, office of the
president, Haight Ashbury Free Clinic and managing editor of the Journal of
Psychoactive Drugs.
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