Women: Research and Policy: Part II

In the early 1970s, Nixon's War on Drugs began primarily to combat rising drug-related crime. This war had a heavy medical-rehabilitative orientation in which deviance was seen as illness. For example, it was during the early 1970s that MMT became institutionalized (71). Simultaneously (and not coincidentally) increased federal funds for drug research became available. Drug-using women were seen as victims, "sicker" than their mate counterparts. When the Reagan-Bush War on Drugs escalated in the 1980s, users of illegal drugs were no longer seen as ill but bad, and culpable for their drug-related problems. Women bore the brunt of drug scapegoating, defined as epidemiologically dangerous and responsible for the spread of HIV to the heterosexual community. By the late 1980s, women drug users had become the less-than-human "crack moms" who were blamed and punished for creating a generation of permanently impaired children.

The increasing size and scope of the problem of women's substance abuse has been exacerbated, if not caused, by two national trends. First, poverty, homelessness, substandard education, and health care have increased since 1980 (253). As members of America's ever-growing "underclass," drug users' lives have become more chaotic, risky, dangerous, and violent (254). Second, for addicts without financial resources, access to drug treatment has become increasingly problematic due to a decline in federal funding of programs since 1976 (255). Although the Office of National Drug Control Policy advocates a shift in funding from enforcement to prevention and treatment, thus far drug users have experienced little change in access (256, 257). Ironically, if monies and availability were increased, it seems unlikely that even the best form of drug treatment could reverse the deleterious effects of the social and political policies of the 1980s and 1990s. Lacking a chance at the American Dream and a "stake in conventional life," drug abusers will continue to relieve their suffering through the use of pain-killing and euphoria-producing substances (258, 259).

The "drug problem" has more to do with social conditions than drugs, and this chapter's recommendations are in agreement with Canadian Susan Boyd's recommendations about pregnancy and drug use:

Exposure to toxic environments, malnutrition, lack of housing, lack of income or poor antenatal care have adverse effects on pregnancy outcomes. If pregnancy outcomes were truly a "health issue" Canadians might consider eliminating the social environmental variables affecting pregnancy rather than stigmatizing a generation of children and their mothers. (183, p. 188)

In addition to these "environmental" factors, a wholly revamped society that is truly open and receptive to a range of life options available to all would also help relieve these problems. In the meantime, drug treatment should be expanded and embellished and a policy of harm reduction toward drugs instituted immediately.

Treatment

In general, more treatment slots are needed for both men and women drug users. Under the current inadequately-funded system, there are long waiting lists and "treatment on demand" is anything but a reality, resulting in an underserved population of women (242, 249, 260). The lack of treatment slots is particularly glaring for pregnant women. In 1990, Wendy Chavkin conducted a survey of drug treatment facilities throughout New York City and found:

The general shortage of treatment slots is aggravated by the unwillingness of many drug programs to include pregnant women. A recent survey in New York by the author revealed that 54% of treatment programs categorically excluded the pregnant. Effective availability was further limited by restrictions on method of payment or specific substance of abuse. Sixty-seven percent of the programs rejected pregnant Medicaid patients and only 13% accepted pregnant Medicaid patients addicted to crack. (261, p. 485)

Another survey conducted in the same year found of the approximately 675,000 pregnant women in need of drug treatment nationwide, less than 11 % received it (173, p.28). Most treatment facilities are unprepared and inadequate to the multiplicity of needs of pregnant women. Separate clinics or clinics within clinics must be instituted.

Current treatment models are male-oriented and not prepared to address women's multiple needs (17, 50, 81, 224, 262-267). For 25 years, since the expansion of drug treatment, women have been motivated to enlist themselves in programs, primarily to get out of "the life" and better fulfill their mothering roles. Currently, a majority of inpatient treatment programs require a minimum 30-day commitment and some are as long as one year. For a woman with young children, this can be an insurmountable obstacle (268, 269). In 1981, the author wrote the following:

[L]ive-in treatment facilities -either equipped for detoxification or opiatefree -work better than other modalities (outpatient detox or methadone maintenance). For a woman addict, live-in treatment is currently possible if she has no commitments; to the 70 per cent of the women in this sample who were mothers, treatment facilities without accommodations for children are of no use. (17, p. 126)

Little has changed in the ensuing 15 years. Women who have substance abuse problems are still unable, for the most part, to find inpatient services that will accommodate their children. Those women who need outpatient services are also in need of assistance with their child care responsibilities, such as supervised play areas for children within the treatment facility. In the context of counseling, programs also should be sensitive to women's privacy needs (17, 264, 265, 270),

All treatment modalities that serve women must be sensitive to their special needs, including counseling, family therapy, and ancillary services such as transportation, child care, children's health services, housing, legal assistance, and job or vocational training. They must also be sensitive to women's diverse cultural needs. Ideally, alternatives to the current system might include women-only treatment programs, inpatient programs that accept children, expansion (and in some areas of the country, creation) of clinics for pregnant women, special job training programs for women and long-term commitment of funding for after care.

Both women drug users and treatment professionals must participate in the institutionalization of advocacy groups which could influence the formulation of treatment policy. Such organizations would go a long way in combating the depression, isolation, and low self-esteem that persists among women in treatment (262, 264, 265, 270, 271). Treatment providers also need the support provided by gender-specific and in-service training in order to decrease burnout and increase program efficacy (272). Finally, public policy makers (e.g., legislators) need to be educated by treatment professionals as well as clients to the needs of this population (208).

Treatment facilities also need to acknowledge the devastating impact of HIV on women drug users, and incorporate AIDS education into their programs. HIV-positive women need special attention. Drug treatment facilities must alter their admission criteria and treatment methods to accommodate this population. They should include comprehensive services, including parenting and employment skills, workshops, and access to health care, and incorporate research and evaluation components with planned dissemination of results (273).

A Policy of Harm Reduction

Drug use has been with us for centuries and is part of our cultural, and perhaps biological heritage (274, 275). Given current social and economic policies that limit life options, the sale and use of intoxicating substances is not likely to disappear, despite our most fervent efforts at "zero tolerance." Americans do not like to admit failure, although the task of eliminating illegal drug use was impossible from the outset. Instead, we should look seriously at the adoption of "harm reduction" strategies instead of futile attempts to eliminate drug use completely. Harm reduction is a set of principles that defines abstinence from drug use as just one of several means of reducing drug-related problems. It is a simple concept, not a camouflage for radical change in drug policy, first implemented in Europe and Australia and used primarily to deal with the AIDS crisis. Those who subscribe to a harm reduction perspective deplore, yet accept, the inevitability of drug abuse. They advocate working with users to minimize the harms brought about by abuse, even if drug use itself cannot be stopped (246). Harm reduction shifts the focus away from idealistic long-term goals, such as abstinence from all drug use, toward more attainable short-term goals such as safer behaviors.

As noted earlier, women studied by the author, whether pregnant and using drugs, or enrolled in treatment, attempted to reduce drug-related harm for themselves and their offspring. These efforts should be encouraged and facilitated. Women should have better information so their efforts are more effective. Those who intervene should stop punishing pregnant women and instead facilitate their harm reduction efforts. Women should have access to health, care without the risk of losing their baby to social services or humiliation. They should have access to treatment that does not require total abstinence. Finally, professionals in research and treatment must learn to settle for less, because insisting on absolute perfection may exacerbate the problem.

Motherhood is at the core of many drug-using women's identities. They love and care very much about their children, who often provide the impetus for harm reduction through exiting "the life" or instituting safer behaviors. Since American society is currently consumed with "family values," drugusing women should derive some of the benefits of this perspective. To begin, they should have the resources to raise children in this country -to feed, house, clothe, and educate them. On the meager, subsistence level provided by our government (which is currently being reduced), paying the rent, providing food, and buying clothes and school supplies are nearly impossible. When women take refuge from this depressing, hopeless, and seemingly endless existence through drugs, social service agencies threaten to take away their most precious "possession." Their children are placed in foster care or with relatives, where they may "bounce around" for years. Loss of custody results in a further spiraling into drug abuse and the commitment on the part of women to have another "replacement" baby in order to regain one's ideal image of oneself as a competent mother" (276, p. 149), Obviously we should weigh levels of harm and rethink social service policies. Rather than removal of custody, we should provide women with the resources needed to raise children.

Treatment, as noted in earlier sections of this chapter, should be expanded and sensitized to women's needs. In addition, a harm reduction perspective within the context of drug treatment should be instituted. Women often enlist in programs when their drug careers are at the height of risk and chaos. The recovery process is slow, and requires an extended period of time during which the woman is not always abstinent from drugs. Treatment should be seen as a process of harm reduction, during which deleterious behaviors are gradually eliminated. For example, if a woman enters treatment with a 365-day "habit" and after a month reduces her drug use to weekends, this should be seen not as failure but as progress. The very last action taken by a treatment program should be to terminate the woman from the program. Instead, she should be encouraged to stay in treatment and further reduce the harms related to her drug use.

Alternatives to incarceration that reduce harm should be explored and instituted. Teresa Albor argues:

In an immediate and practical sense, it is time to recognize that there are forms of punishment for women that are more effective, less expensive and cause less disruption to families. These include small model programs in which mothers live with their children while serving sentences, community correction or restitution and home-based confinement using electronic monitoring. Instead of building more prisons for women, we should use scarce resources for prison-based reproductive health counseling, education, vocational training and post-release programs, which provide former inmates with continued access to alcohol and drug treatment and other emotional support. And if mothers must be in prison, it is essential that they be able to get together with their children for weekend retreats, or that transportation be provided for the children so they can visit their mothers.

It is time to raise the more radical question of whether most women offenders should be incarcerated at all. Most female prisoners don't belong in prison and are harmed by the experience. Most are women whom society has failed. When we lock them up, separate them from their children, provide inadequate health care and rehabilitative services and treat them as loathsome and irresponsible criminals, that failure is amplified. Removing women from their families perpetuates cycles of criminality and dysfunction by both the mothers and their children. The ultimate cost to society is far greater than if these families had not been torn apart. (277, p. 237)

Needle exchange programs have been shown to reduce syringe-related HIV risk in the general population of IDUs and for women in particular (278). The Clinton Administration should stop suppressing evidence of the efficacy of syringe exchange and make this harm-reducing program fully accessible to both women and men.

The United States has been slow in adopting harm reduction strategies (246, 279, 280). A notable exception is MMT which has been used, but not without controversy, for some 30 years (71). This is largely due to fear on the part of policy-makers that a harm reduction message will encourage increased drug use among current users and lead to the initiation of new users (281). In fact, there is no evidence to suggest that harm reduction strategies such as safe drug-using messages, needle exchange programs, and greater access to treatment increase drug use (280, 282-284). We can only hope the continued failure of criminal justice/interdiction strategies will eventually enlighten Americans to the only pragmatic course regarding women (and men) who use drugs, the institutionalization of harm reduction as policy.