International Aspects of Social Work Practice in the Addictions

Shulamith L A Straussner, Larry Harrison

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317718727
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Examine the worldwide phenomenon of substance abuse and addiction!

International Aspects of Social Work Practice in the Addictions examines current social work practice in the addictions around the world. Researchers and practitioners address the abuse of and addiction to alcohol and other drugs and the current policies impacting the treatment of these substances in different countries. The book looks at the substances abused, the scope of the problems, the social reactions, the treatment approaches, and the role of professionals in addressing issues unique to each country, providing a more critical understanding of the socioeconomic and cultural influences on treatment systems.

International Aspects of Social Work Practice in the Addictions presents cross-cultural perspectives on the effects of substance abuse and addiction on social policies, institutional practices, sources of funding, and social work methods. The book examines the rapid social changes that go hand in hand with increased rates of psychoactive substance problems and recognizes addiction as a complex biopsychosocial phenomenon that responds to intervention. The countries represented by the book's contributors include:

• Israel
• Ireland
• Germany
• Australia
• Singapore
• the Netherlands
• the United Kingdom
• the former Soviet Union
• and the United States

International Aspects of Social Work Practice in the Addictions also includes book reviews related to cultural issues and a roundtable discussion concerning the legalization of drugs with perspectives from Australia, the United Kingdom, and the United States. This unique book is a vital resource for clinicians, academics, and researchers.

ARTICLES

War and Peace: Social Work and the State of Chemical Dependency Treatment in the United States

Diana M. DiNitto

Diana M. DiNitto, PhD, is Cullen Trust Centennial Professor in Alcohol Studies and Education, The University of Texas at Austin School of Social Work, Austin, Texas (E-mail: [email protected]).

SUMMARY. In recent decades, treatment for alcohol and drug problems in the United States has been influenced by a number of factors. This article discusses several of these factors, including the “War on Drugs,” with its emphasis on law enforcement and interdiction, and managed health care, which has compromised access to treatment. In spite of these factors, the U.S. invests a goodly amount in alcohol and drug prevention and treatment services and research. Efforts are being made to ensure that research findings are being translated into improved clinical practice. Among the controversial issues in the treatment arena are recent efforts by the Bush administration to promote public funding of faith-or religious-based groups in delivering chemical dependency services. Social workers commonly see people with alcohol and drug problems in their practices, but only a small number of social workers are well prepared to treat this group of clients. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Addiction treatment in U.S., chemical or substance dependency, substance abuse, social work, policy, war on drugs

INTRODUCTION

This article considers the state of substance abuse treatment and related issues in the United States (U.S.) and their relevance to social work practice. The material is grouped under five headings: (1) the “war on drugs,” (2) access to chemical dependency treatment, (3) transferring advancements in research and treatment technology, (4) keeping the faith, and (5) social work credentialing and chemical dependency treatment.

THE WAR ON DRUGS

The “war on drugs” is the most recognized description of the U.S. approach to drug problems. The U.S. has waged this war since it began fashioning the Harrison Narcotics Act of 1914. The current war effort began during the Nixon administration (see Gray, 1998). During the 1980s, President Ronald Reagan escalated this effort, culminating in the establishment of the Office of National Drug Control Policy (ONDCP). ONDCP’s director, dubbed the “drug czar,” became a Cabinet level official (top presidential adviser). For recent U.S. presidents, alcohol and drugs became personal as well as public policy issues. The Betty Ford Center, probably the most highly visible addiction treatment center in the world, is named for the wife of a former president who has dealt with her own addiction. Former President Bill Clinton admitted trying marijuana, and members of his own family have had alcohol and cocaine problems. Current President George W. Bush has a conviction for driving under the influence of alcohol and has chosen to abstain completely from drinking alcohol. He has declined to discuss other drug use, although both his daughter and his niece have had legal problems due to the use of alcohol or drugs.

Crime and Punishment

The nation’s current $20 billion federal drug control budget (ONDCP, 2001) may seem astonishing to those in other countries. During the administrations of former Presidents Bush and Clinton, about two-thirds of the national drug control budget went to law enforcement and interdiction, and one-third to prevention, treatment, education, and research (ONDCP, 1999). This allocation contradicts what we know about the success of “supply” versus “demand” side strategies. There is a savings of about $12 in criminal justice, health care, and related costs for every $1 spent on treatment (National Institute on Drug Abuse [NIDA], 1999). Nevertheless, a 2001 national opinion poll conducted found that while 74% of Americans feel that the U.S. is losing the drug war, 52% said that the government should emphasize “stopping drug importation” (Pew Research Center, 2001). Only 36% thought that drug treatment should be emphasized.

Drug crimes are the single greatest contributor to the phenomenal increase in incarceration in the U.S. According to the ONDCP (1998), between 1985 and 1995, almost three-quarters of the increase in the federal prison population was due to drug offenses, and the state prison population incarcerated for drug-law violations increased by 478%. In 1999 alone, there were more than 1.5 million arrests for drug violations (ONDCP, 2001). Of all drug law violations, 80% were for possession of illegal drugs, and drug and alcohol offenses accounted for nearly one-third of the nation’s arrests. Meanwhile, conservative estimates are that about 13 to 16 million Americans need substance abuse treatment, but that only about 3 million receive it, resulting in a large “treatment gap” (Center for Substance Abuse Treatment [CSAT], 2000).

In an effort to blend criminal justice and treatment approaches, more substance or chemical dependency treatment is being conducted in jails and prisons and through criminal justice diversion programs (see Coffey, Mark, King, Harwood, McKusick, Genuardi et al., 2001; McNeece & DiNitto, 1998). A substantial number of probationers and parolees also participate in some type of chemical dependency treatment. An example of in-prison treatment is the 520-bed New Vision modified therapeutic community for male inmates located in Kyle, Texas. The facility is also notable because it is operated by a private, for-profit company, the Wackenhut Corrections Corporation. Privatization of public services has become common (see DiNitto, 2000), and chemical dependency treatment professionals find themselves working in a variety of venues.

Reforming Welfare and Education

Many policies in addition to incarceration constitute the drug war (see DiNitto, 2000). The Americans with Disabilities Act of 1990 provides employment protections to those with past alcohol and other drug problems. However, it does not provide those who currently use illegal drugs or whose job performance is impaired by alcohol with the same level of employment protections as offered to individuals with other disabilities (see de Miranda, 1990; Program on Employment and Disability, 2001). Though many alcoholics and addicts have paid into the Social Security Disability Insurance (SSDI) program while employed, alcohol and drug addiction do not qualify as disabilities in this program. Alcohol and drug addiction are also not qualifying conditions for the nation’s public assistance program for poor people with disabilities called Supplemental Security Income (SSI) (see Coffey et al., 2001; Committee on Ways and Means, 1998, pp. 302–304; Conklin, 1997; DiNitto, 2000; McNeece & DiNitto, 1998). Without entitlement to SSDI or SSI, alcoholics and addicts may also be unable to participate in the nation’s major publicly-supported health care programs.

The federal Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, known as “welfare reform,” made massive changes in the federal Food Stamp Program (FSP) and the major state-run public assistance programs for poor families with children, now called the Temporary Assistance for Needy Families (TANF) program (DiNitto, 2000). For example, convicted drug felons are barred from TANF and FSP forever unless the state passes a law to opt out or modify this provision (see Adams, Onek, & Riker, 1998). Their children retain the right to benefits, but there is less help for the entire family. States can also test adult TANF recipients for drug use and penalize them if they test positive. Though few have resorted to “suspicionless” testing, some have adopted testing based on suspicion of use or other screening techniques, including self declaration (Carey, 1998). The federal Department of Housing and Urban Development’s “one strike” policy means that public housing tenants can be evicted for drug use or related activities and, although declared unconstitutional by the 9th Circuit Court, in some communities or jurisdictions innocent individuals residing with drug users or sellers may be evicted as well (“Court overturns …,” 2001).

Under the current federal Higher Education Act, students with adult drug convictions are denied federal financial aid to attend college for varying lengths of time (see “Injustice 101 …,” 2001). Public school districts have used “zero tolerance” policies to suspend or expel children who are found with banned substances (see “Schools reconsider …,” 2001). Some public school districts have mandated drug testing of all high school students. Penalties for refusing to be tested include bans on participating in extracurricular activities. The American Academy of Pediatrics believes that without strong medical or legal justification, involuntary testing is not appropriate for young people while the Academy believes that there is cause for concern about psychoactive drug use, the response should be referral to a qualified professional (Committee on Substance Abuse, 1996, p. 305). Given constitutional challenges, such as unreasonable searches, the U.S. Supreme Court will take up the issue of drug testing of school children (“U.S. Supreme Court to advise…,” 2001).

Though the benefits of widespread drug testing of employees are questionable, it has become an increasingly common practice (Normand, Lempert, & O’Brien, 1994). Drug testing in the workplace usually fails to address the abuse of alcohol-the substance most often associated with job performance problems.

The war on drugs has been branded as discriminatory and racist. Though the prosecution of women for fetal endangerment does not hold up well under judicial scrutiny, women, particularly poor women, have been arrested or incarcerated for drug use while pregnant (see Paltrow, Cohen, & Carey, 2000). There are also concerns that children’s protective services are not addressing parental alcohol and other drug use appropriately. Penalties for possession of crack cocaine, which is readily available in poor communities inhabited disproportionately by members of particular ethnic groups, are much harsher than penalties for possession of powdered cocaine, which is more expensive to obtain. African Americans have been hit hardest by this disparity (see United States Sentencing Commission, 1995, 1997).

Will the War Abate?

Conspicuously absent from the drug war are many aspects of harm reduction-in particular, needle exchange. Although the federal Department of Health and Human Services (DHHS) has acknowledged the benefits of needle exchange (e.g., reduced HIV transmission and no encouragement of injection drug use), it has refused to fund such programs, saying that the decision should be left to local communities (“Research shows … ,” 1998). Provision of clean syringes to drug addicts remains illegal in most jurisdictions. Individuals who operate such programs risk arrest, though law enforcement may not interfere with their efforts.

There is some evidence that the drug war may be abating. For example, the number of community drug courts, which offer treatment in lieu of prosecution to first-time and low-level, non-violent drug offenders, is increasing (ONDCP, 2001). California voters recently approved Proposition 36; it diverts all first-and second-time non-violent drug possession offenders to treatment rather than incarceration (Vallianatos, 2001).

ACCESS TO CHEMICAL DEPENDENCY TREATMENT

The U.S. spends a greater percentage of its gross domestic product on health care than all other developed countries, yet fewer Americans are covered by health insurance than citizens of these other countries (Organization for Economic Cooperation and Development [OECD], 2001). Those with health insurance usually have some coverage for alcohol and drug dependence treatment.

In the U.S., private practitioners provide most health care, and health insurance is generally obtained through one’s employer (for an overview of U.S. health care policy, see DiNitto, 2000). There are two major publicly-supported health insurance programs, designed largely to cover those outside the workforce. Medicare, a federally administered social insurance program (employers and employees pay into the program during the employee’s working years), covers virtually all those aged 65 or older. Medicaid, a public assistance program financed jointly by the federal government and the states, covers poor Americans who must also meet other eligibility criteria, such as being under age 18, being pregnant, or having a disability (other than alcohol or drug dependence) that prevents gainful employment. Medicaid and Medicare generally cover chemical dependency treatment (see Coffey et al., 2001); however, most poor Americans do not qualify for Medicaid because income and assets limitations are so stringent, or because they do not meet other eligibility criteria. Many physicians (and other practitioners) accept Medicare’s federally-established reimbursement rates, but most do not accept Medicaid because state-determined reimbursement rates are so low. The type and extent of Medicaid coverage for chemical dependency (and many other services) varies considerably by state (see McNeece & DiNitto, 1998).

Fourteen percent of Americans did not have any public or private health insurance coverage in 2000 (U.S. Bureau of the Census, 2001), and therefore, had no coverage for chemical dependency treatment. Many others were not insured during part of the year. Many of the uninsured are the “working poor.” Their employers do not provide health insurance or they are self-employed, they do not meet Medicaid requirements, and they cannot afford to purchase health insurance on their own. Unless those who are uninsured and need chemical dependency treatment can afford to pay for private care out-of-pocket, or unless they rely solely on no-cost services like Al...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• ARTICLES
• SPECIAL TOPICS
• ENDPAGE
• Index