DRUG TREATMENT ISSUES

How available is methadone treatment in Pulse Check communities? Methadone maintenance is still not available in Billings or Sioux Falls. As reported in the past two Pulse Check issues, about half of the epidemiologic/ethnographic sources in the remaining cities—mainly in the South—consider methadone to be available in selected areas only, while the other half consider it available throughout their areas. Four sources (in Baltimore, Los Angeles, Seattle, and Washington, DC) report that methadone maintenance is somewhat more available since the last Pulse Check.

Exhibit 1.
How has illicit drug use impacted the health of users?

City/Source		Adverse Conse- quence	Comments
HIV/AIDS	Baltimore, MDN
	Billings, MTN
	Philadelphia, PAM
	Seattle, WAM		Increased particularly among Blacks and those who inject
	Washington, DCN		Mostly due to unprotected sex and prostitution among drug users
	Columbia, SCM
	Portland, MEN		Heroin increased in potency so injection declined.
Hepatitis C	Baltimore, MDM,N		Unsafe sex, sharing needles
	Billings, MTN		Sharing needles
	Boston, MAN		More testing; 85 percent of patients are positive
	Chicago, ILM		More testing; about 75 percent of clients are positive
	Denver, COM,N		More testing; 70 percent of clients are positiveM; many clients were originally diagnosed with hepatitis B, but have been retested with more sensitive tests that indicate hepatitis C
	El Paso, TXN		Increases in injecting
	Los Angeles, CAM		More testing has resulted in higher reported rates of hepatits C
	Miami, FLM		More testing has resulted in higher reported rates of hepatits C
	Philadelphia, PAN		More testing has resulted in higher reported rates of hepatits C
	Portland, MEM,N		More testing has resulted in higher reported rates of hepatits C
	St. Louis, MOM,N		More testing; large problem, especially among people older than 40
	Seattle, WAN
	Washington, DCM
	Memphis, TNM
Auto Accidents	Billings, MTN
	Columbia, SCM
	Washington, DC
High-Risk Pregnancies	Billings, MTN
	El Paso, TXM		Clients are having unsafe sex and contracting STDs.
	Los Angeles, CAM
	Seattle, WAN
	St. Louis, MOM		More women are presenting at hospitals.
	Washington, DCN		Increasing, especially among young adults
	Columbia, SCM
Overdoses	Billings, MTN		Related to prescription opiates, especially OxyContin® and methamphetamine; stronger methamphetamine now available and causing ODs
	Columbia, SCN,M		Increases in drug combinations, especially alcohol and prescription pills, such as alprazolam (Xanax®) or hydrocodone (Vicodin®)
	Philadelphia, PAN		Higher quality of heroin available
	Portland, MEM,N		Increases in the combination of drugs including heroin, crack, and benzodiazepines
	St. Louis, MOM
	Philadelphia, PAM
Tuberculosis (TB)	Baltimore, MDN		Related to crack and nicotine use
	Boston, MA
	Columbia, SCM
	Memphis, TNM
	St. Louis, MOM
Sources: Methadone and non-methadone treatment providers

Five epidemiologic/ethnographic respondents report adequate capacity of public methadone maintenance, while seven (in Baltimore, Chicago, Detroit, El Paso, Honolulu, St. Louis, and Seattle) report having waiting periods of 1–12 months. Since the last Pulse Check, public methadone maintenance capacity has decreased somewhat in Chicago. Private capacity, however, has increased in four cities (Memphis, Miami, New Orleans, and Portland [ME]), although waiting lists are reported by six sources.

How has drug abuse impacted the health of clients in treatment? (Exhibit 1) Since the last Pulse Check reporting period, the impact of drug use on AIDS and HIV status seems to have stabilized in the majority of methadone and non-methadone programs, except as listed in exhibit 1. By contrast, reported cases of hepatitis C continue to increase among drug users in programs across the Nation, nearly always because of increased screening and awareness. High-risk pregnancies, drug-related auto accidents, and overdoses (usually involving a combination of drugs) increased in several cities, but most levels remain stable. Tuberculosis (TB) has decreased in four cities and increased only in Baltimore.

What barriers face drug treatment in Pulse Check cities? (Exhibit 2) Methadone and nonmethadone treatment programs across the country report many barriers to drug treatment. The most commonly mentioned barriers are limited slot capacity (a situation often caused by lack of funding), lack of trained staff to treat comorbid mental health disorders, and violent behavior among presenting clients. Several sources (in Chicago, Honolulu, Los Angeles, Portland [ME], St. Louis, and Seattle) report that funding has recently been cut, which has decreased slot capacities and increased waiting lists. Other common barriers to treatment include lack of transportation for potential clients and difficulty recruiting trained staff. Many programs cannot treat clients younger than 18 years, but these clients are often referred to programs designed especially for adolescents.

Have diagnoses of psychiatric comorbidity been shifting in treatment programs? Mood and conduct disorders are the most commonly reported mental health diagnoses among drug treatment clients, according to Pulse Check respondents. These types of diagnoses are generally stable, but increased levels or stable-at-high levels are reported in several cities:

Exhibit 2.
What are the barriers to drug treatment in different Pulse Check cities?

City	Limited slot capacity/ Waiting list	Lack of trained staff to treat comorbid clients	Violent behavior among clients	Comments	Other barriers
Baltimore, MD				The program has 56 vacant slots but 545 on the waiting list. It is difficult to compete with private treatment programs’ salaries for trained staffM.	Difficulty recruiting trained staff due to change in the certification processM; lack of comprehensive servicesM; lack of transportation or money for transportationN
Billings, MT				This program lacks licensed addiction counselorsN. Disruptive behavior disorders, especially among younger clients, seem to be increasing and problematicN.
Boston, MA				This program turns away about 25 potential clients plus 3 drug treatment requests from jails per weekN.	Difficulty recruiting trained staffM; lack of recovery homes in the Boston areaN
Chicago, IL				The Illinois Department of Public Aid cutting transportation by 75 percentM. Violence occurs if one particular gang overrepresented within the program.N	Lack of transportation or money for transportationM,N; lack of medical doctorsM; gang affiliation among clientsN
Columbia, SC				These programs are hiring more staff within the next 6 months, so slot capacity should become more adequateM,N.
Denver, CO				Demand outweighs resources for this program, and the funding is perceived inadequateN. Treatment programs seem have either substance abuse or mental health treatment services, but there is not enough overlapN.
Detroit, MI					Lack of trained staffM
El Paso, TX				More money and staff are needed to help with more clientsM.
Honolulu, HI				Funding is low and has been cut recently due to a poor economyN. Violent behavior among presenting clients is methamphetamine relatedN.	Lack of fundingM
Los Angeles, CA				Funding has been cut recentlyN. Comorbid disorders have been increasingN.	Lack of funding, especially among low-income adultsM; lack of English language skills among students and parentsN
Memphis, TN					Lack of resources for drugs that don't require medical detox (especially marijuana and crack)N
Miami, FL				Funding is lowN.	Lack of in-home treatment resourcesN; lack of services to treat families as a wholeN
New Orleans, LA
New York, NY				This program reports difficulty in hiring trained staffM. Many violent clients are mandated by the courts to participate in anger management coursesN.	Clients unable to payM; lack of child care for clientsM
Philadelphia, PA				This program employs one psychiatrist with limited time per week, so they refer psychosis patients to mental health facilities that may lack expertise in substance addictionN.	Low reimbursement ratesM
Portland, ME				This program reports chronic waiting listsN. The barrier of lack of trained staff to treat comorbid disorders is improvingN.
St. Louis, MO				Many State-funded detox services were cut recentlyN.	Lack of State fundingN; lack of safe, healthy, affordable, drug-free housingN
Seattle, WA				One hundred people are currently wait- listed, and public subsidy slots have been filled since the beginning of yearM. In the last 6 months, capacity has been halved due to funding cutsN.	Lack of mental health services in the countyM; lack of inpatient careM
Sioux Falls, SD					Lack of fundingN; families not following recommendationsN
Washington, DC

• Billings, MT^N: Recent increases in several diagnoses—including conduct disorder, psychosis, mood disorder, and suicidal thoughts and attempts—reflect the overall increase in the use of illegal drugs.
• Columbia, SC^M: An increase in conduct disorders has resulted from clients unhappy about being held accountable for positive urinalyses.
• El Paso, TX^N: An increase in conduct disorders among the younger age group reflects improved diagnostic capabilities. An increase in suicidal ideations is also noted.
• Memphis, TN^N: Comorbidity is stable at high levels, reflecting a major need for the community’s jail system to triage with the mental health system. Prisoners often receive medication, such as antipsychotics, antidepressants, and mood stabilizers, while in jail. Often, however, they are released—sometimes at 2:00 or 3:00 a.m.—without discharge medications. Within a week, these individuals start decompensating. Some use cocaine or marijuana to stabilize their moods. Some end up in emergency departments and are subsequently referred to treatment.
• St. Louis, MO^M: Treatment staff are more aware of dual diagnoses than in the past and are working more closely with mental health centers. They are therefore increasingly diagnosing conduct disorders, mood disorders, and suicidal thoughts and attempts.
• St. Louis, MO^N: The recent opening of an adolescent drug treatment program has led to an increase in diagnoses of conduct disorders. Additionally, large funding cuts in the private sector have led to more people with drug-related psychosis, schizophrenia, depression, and bipolar disorders being referred to this program.
• Seattle, WA^M: An apparent increase in comorbidity diagnosis numbers actually reflects an increase in ancillary services.

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The following symbols appear throughout these Highlights to indicate type of respondent: ^LLaw enforcement respondent, ^EEpidemiologic/ethnographic respondent, ^NNon-methadone treatment respondent, and ^MMethadone treatment respondent.