Best Practices : Substance Abuse Treatment and Rehabilitation

4. Special Populations

a) General Considerations

While the evidence for client-therapy matching is currently still weak, it is possible that certain populations or subgroups benefit from special attention because of their unique characteristics or because general programming does not adequately meet their needs. So, for a number of years, treatment programming has been designed for various "special populations," based on an understanding of shared characteristics that are thought to have relevance in attracting, motivating and retaining clients in treatment. However, as yet, there is little scientific research to show that clients from special populations experience improved treatment outcomes as a result of specially designed treatment interventions.

To define special populations, the Institute of Medicine (1990) distinguishes between structural and functional characteristics. Structural characteristics are those that define a population on a demographic basis, either by a fixed characteristic (i.e. gender, race or ethnicity) or a developmental characteristic (age). Functional characteristics are those social, clinical or legal conditions which are shared by a group of people, even if those individuals do not see themselves as a group (e.g. being homeless, having a co-occurring psychiatric disorder, being incarcerated, being an impaired driver or sharing a common diagnosis such as AIDS). A problem in defining special populations is that individuals may possess several structural or functional characteristics that need to be accounted for in planning treatment (e.g. an adolescent female who may also have a psychiatric diagnosis).

According to Landry (1995), there are few studies that show significant effect from treatment based on either structural or functional characteristics. Nevertheless, in Canada, special provisions for treatment or for ancillary services are often made for women, adolescents, seniors, clients diagnosed with HIV and those with mental health problems. Measures proposed for these populations generally have the effect of increasing their opportunity for access to help through some combination of: creating greater awareness of and access to informal help such as self-help/mutual aid groups and self-instructional material, greater involvement of general community services in identifying and supporting clients with substance abuse problems, and bringing specialized services to these populations through outreach efforts. Effective case management is particularly important to ensure that the unique and often multiple needs of clients from these populations are met.

b) Women

The Institute of Medicine (1990), reporting on studies conducted over the previous decade, supported the conclusions reached by previous systematic reviews of the treatment outcome literature. These reviews found that there is relatively little information on which specific interventions might be based to increase the probability of successful outcomes of treatment for women with alcohol problems. Landry (1995) states that the few available studies have generally concluded that adult men and women, treated together for alcohol problems in the same program, do equally well. There is less agreement regarding treatment for drugs other than alcohol. There appears to have been little research on the differential effectiveness of different types of treatment designed specifically for women.

Lightfoot et al. (1996) conducted a review of substance abuse treatment for women, with particular reference to the previous five years. The majority of the 211 studies were descriptive, with 7 (2%) specifically examining treatment effects for women using randomized trials, and 7 using non-random assignment or comparative treatments. Three of the randomized trials involved smoking cessation, with mixed results. Two studies compared men and women in three brief cognitive behavioural treatments, concluding that women fared better than men with a manual or brief guidelines, but found no difference in the therapist-based treatment.(Sanchez-Craig et al., 1989; Sanchez-Craig, Spivak and Davila, 1991). The other two studies involved women only, the first, testing approaches to reducing relapse among chronic alcohol abusers and revealing few differences among approaches (Watzl et al., 1988). The final study compared 100 women attending a specialized clinic for women with 100 women in a regular program, with the clinic group showing fewer social and alcohol problems at follow-up (Dahlgren and Willander, 1989).

The non-random or comparative studies were designed to answer questions regarding the needs of women in treatment. Four of the studies addressed drugs other than alcohol. The two largest addressed the cost of poly-drug abuse (Anderson, 1986) and consequences of terminating methadone maintenance treatment (Anglin et al., 1989). The first study found that female emergency hospital registrants given personalized nursing that included home visits had lower drug use and lower estimated economic and social costs compared with those with no home visits. In the second study, Anglin, Brecht and Maddanian (1989) found that the women coped better than the men when methadone maintenance treatment was discontinued.

Most of the literature on women's treatment comprises clinical and descriptive studies that focus on the following approaches: family therapy, group therapy, separate rather than combined treatment with men, and female rather than male therapists (Institute of Medicine, 1990). These options have not been examined using controlled clinical trials, so there is no indication of their particular effectiveness. However, clinicians continue to assert that women's treatment needs differ from men's, and the following observations are well documented (Lightfoot et al., 1996):

• A greater stigma is attached to a woman's substance abuse problem; there is greater resistance on the part of family and friends; there are more negative consequences attached to treatment entry (family responsibilities, lack of child care facilities, job loss, anger from spouse, loss of friends, etc.).
  
• A small proportion of both men and women use specialized services. It appears that women may be less likely to use specialized treatment facilities than men. However, as previously noted, women problem drinkers are more likely than men to view their symptoms as anxiety or depression and to seek help from mental health professionals. This is especially so for women problem drinkers who also have psychiatric problems.
  
• Women also prefer to use informal support networks when they have a large number of problems.
  
• Employee assistance programs are less likely to identify and refer them.
  
• Women prefer treatment which provides a range of related additional programs and services, such as treatment for children and the provision of continuing care.
  
• Women prefer outpatient to inpatient services.
  
• Women prefer treatment where there is provision of child care services.
  
• Increased utilization occurs when other specialized services are available, such as pregnancy and postpartum care; prescription drug use counselling; and legal, vocational, child and sexual abuse counselling.
  
• Women like to be offered vocational skills training, as well as training in assertiveness and parenting skills.
  
• Support services, including transportation and outreach, are helpful.
  
• The factors which create barriers to treatment often lead to premature termination of treatment as well.
  

More research is needed into the relationship between life events and substance abuse for women, in order to provide appropriate treatment. There is considerable evidence that victimization, particularly sexual abuse, may be a causal factor in the development of substance abuse in women. Canadian researchers Groeneveld and Shain (1989) found that women who had been sexually abused as children or adults were at least twice as likely as non-abused women to use medication to help them calm down or to sleep.

Best Practice Guideline (No. 14)

There is insufficient research evidence to support the provision of specific types of interventions for women. However, it is clearly important to consider barriers to treatment and provide a range of modifications and support services (e.g. scheduling sessions while children are in school, the use of self-help materials, provision of child care, transportation), and to provide specific ancillary services (e.g. related to pregnancy, sexual abuse counselling, parenting skills training and vocational assistance).

c) Youth

The adolescent years can be marked by anxiety and confusion. Rapid changes in physical and intellectual development occur while the young person is seeking a sense of personal identity and values. Adolescents are heavier users of drugs such as cannabis, cocaine and crack than adults, although they may smoke fewer cigarettes and drink less alcohol (Smart, 1993). Research indicates that problems in other life areas are common for adolescents with substance abuse problems (Harvey-Jansen, 1995). These include the major life areas of family, school or job, medical, emotional, social relationships and leisure. Problems may exist prior to involvement with substance use or they may arise from the substance abuse. Additionally, substance abuse and problems in these other life areas may be mutually reinforcing.

Consistently, research also indicates that peer association and family factors are most important in contributing to substance use in adolescence. There is growing support for the view that inadequate social conditions, stressful life events, societal pressures and physical or sexual abuse are also major factors in the development of heavy substance use by adolescents, particularly young women (Lundy, Carver and Pederson, 1996).

Despite a large amount of literature about this population, there is little firm information on how best to treat young people for alcohol and drug problems. Overall, the research does suggest, however, that receiving treatment is better than not receiving it (Landry, 1997).

There are few controlled outcome evaluation studies which compare different treatment modalities for youth. In a review by Wilkinson and Martin (1991), only three Canadian studies on treatment effectiveness were found. These reviewers concluded that treatment content was more important than duration and location. In one of the few studies comparing inpatient with outpatient treatment using the same pre-post outcome measures, Wilkinson and LeBreton (1986) found peer group pressure to be a strong factor in successful treatment outcome, with no difference between outpatient and a more costly residential treatment option.

A review of the literature between 1980 and 1993 by Harvey-Jansen (1995) concluded that about 30% of clients (including those not completing treatment) were found abstinent at follow-up. Longer-term outcome is less certain, with high relapse rates generally recorded. When the outcome measure is determined to be a decrease in substance use, rather than abstinence, the improvement rate is estimated to be about 65%, over a longer follow-up period. The studies have found that those who do best in treatment tend to: be female, report shorter length (in years) of substance use; choose to enter treatment; and, be in school.

Clinicians' experience suggests that adolescents benefit most from programs which offer flexible approaches that adjust to individual adolescent needs, provision of family therapy and behavioural skills counselling, the availability of school for dropouts, vocational counselling, recreation services, sexuality counselling, involvement of family or non-abusing support person and continuing care.

An adolescent treatment system was developed in 1988 in Alberta for young people 12 to17 years of age. The service provides treatment for about 1500 adolescents a year through 25 treatment facilities across the province. Treatment goals were to assist in achieving abstinence, to provide education about drug use and skills in decision making, to increase the quality of family and social relationships and to support families through the process of treatment and continuing care. A recent evaluation of this program observed that adolescents who entered treatment had multiple drug use problems over an extended period of time, were experiencing harmful consequences of their use and had difficulties in many areas of their life. Their estimates of outcome were similar to those found in other evaluations, with 69% abstaining or decreasing consumption at three month follow-up and 56% experiencing decreased life problems (Harvey-Jansen, 1995).

Outcome is less favourable when the young person attends treatment designed for adults. Since general treatment programs are usually designed for male adults with relatively serious problems, the program requires considerable modification to meet the needs of youth. Upfold (1997) cautions that assessment strategies, treatment methods and goals must be relevant to the age and stage of development of the client (e.g. early, middle or late adolescence), and include a good knowledge of the physical, emotional and cognitive changes of the adolescent.

A subset of this age group is street youth. The size of this population in Canada is constantly changing and difficult to determine. There are no reliable estimates of the size of the street youth population because of the transitory nature of these young people (Zdanowicz, Adlaf, Smart, 1993).

This population is seen to be at high risk for a number of reasons, including their way of life. For street youth, substance use is one of a number of characteristics of this way of life. Although not a homogeneous group, they share patterns of heavy drug use and serious risk of HIV and Hepatitis C infection. Several studies have found that almost all street youth have used cannabis at some time, and their rates for other drug use, such as cocaine, crack and LSD, are 5 to 15 times higher than for mainstream youth (Smart, 1993). Effective treatment for street youth is likely to be unstructured, held together by case management services, and comprising outreach, low-structured interventions and support services. For this population, case management is critical because of their reluctance to utilize services and their multiple problems (Martin, 1990). However, for this population, it is often a change in lifestyle (e.g. obtaining adequate long-term living arrangements) rather than treatment that marks the end of substance abuse.

Smart (1993) describes a number of changes which had occurred in the types of treatment offered for young drug abusers over the previous 10 years:

• There are more alcohol- and drug-dependent youth participating in all types of treatment.
  
• There are indications that the percentage of females in treatment is increasing, and the average age is decreasing.
  
• Cases of cocaine and narcotic abuse requiring treatment have increased, while cases involving alcohol, cannabis⁵ and tranquillizers are decreasing. There is essentially no change in cases involving hallucinogens or solvents.
  
• Use of therapeutic communities is changing to include clients with problems other than substance abuse.
  
• There is a trend away from hospital and inpatient programs to community-based outpatient programs.
  

In reviewing the literature, the Institute of Medicine (1990) concluded that a number of issues need to be addressed to improve youth treatment:

• the lack of precision in and agreement on the definition of alcohol abuse for youth;
  
• design of clinical studies comparing the variety of treatment approaches recommended as a result of clinical experiences;
  
• concern for overuse of inpatient rehabilitation programs;
  
• disagreement over the need to provide combined substance abuse or alcohol-focused treatment; and
  
• controversy over the need for age-segregated facilities.
  
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Best Practice(No. 15)

Adolescents may respond best to flexible Guideline approaches which adjust to individual needs. Important program elements include family therapy, behavioural skills counselling, family and peer support and continuing care. Ancillary services, such as the availability of school for dropouts, vocational counselling, recreation services, psycho-social development, crisis counselling and sexuality counselling, are also important.

d) Seniors

Alcohol is the most commonly used psychoactive substance for seniors aged 65 years or older. Although their level of alcohol and tobacco use is lower than younger age groups, their prescription drug use is higher, particularly women's use. Canada's Alcohol and Other Drugs Survey (Health Canada, 1994) reports that use of prescribed tranquillizers, sleeping pills and antidepressants by Canadians increases with age, with 27.4% of those 65 or over using one or more medications. This may arise from the acceptability of using these drugs, where social controls and perception of appropriateness reduce women's use of alcohol (Graham, Carver and Brett, 1996).

In addition to substance abuse problems, seniors may experience many difficulties in daily living, such as home skills, self-care, transportation and shopping. In addition, older adults may be isolated and have experienced multiple losses, financial problems or abuse from family members. They may be more reluctant to admit to having a substance abuse problem and seldom ask for help. Therefore, individuals in need of help rarely enrol for substance abuse treatment, but are more often identified through other health or social services.

Compared with adults under 65 years of age, seniors with alcohol problems have been found to have a higher rate of cognitive deficits, lower maximum alcohol consumption, a greater need to drink before breakfast, a higher likelihood of being unable to stop drinking and more acute medical problems (Graham et al., 1989). Due to the effects of the aging process, older adults are more likely to experience problems at lower levels of alcohol and drug use, because they are in general more sensitive to drug effects and experience more adverse reactions to drugs than younger populations. Alcohol and drug problems are most commonly accompanied by multiple or severe medical problems, either caused or aggravated by the substance use.

Two major subgroups have been identified with alcohol problems, with different etiology and prognosis. Early onset clients comprise about two thirds of seniors with problem drinking. They generally have a long-term history of problem drinking, may have serious physical complications and are likely to have poor prognoses. Late onset problem drinkers typically start drinking in response to a serious life event, with better prognoses (Institute of Medicine, 1990). Graham et al. (1989) have found the term "late onset problem drinkers" rather ambiguous, particularly since such drinkers may start drinking in their 40s. They identify another subgroup which comprises clients who have dangerous alcohol use because of drug interactions. In addition, Baron and Carver (1997) describe four phases in the drinking history of seniors: early, as the senior begins to move from moderate social drinking to using alcohol to cope with the stresses of life; acute, experiencing symptoms associated with present consumption or withdrawal from alcohol or other drugs; chronic, in which the senior experiences ongoing physical, psychological or social symptoms associated with alcohol or other drugs; and, recovering, as the senior decreases consumption to non-hazardous levels.

It is generally conceded that in many cases traditional treatment programs are not appropriate for seniors. Seniors may have difficulty leaving their homes and accessing treatment programs, they may not be ready to identify a goal of abstinence or reduced use, and the pace and content of programs may not be appropriate for them. For these reasons, treatment is better offered in a community-based setting, and substance use problems addressed within the broader context of health and activities of daily living (Martin, 1990; Baron and Carver, 1997). Characteristics associated with poorer prognosis are chronic physical problems, psychiatric co-morbidity, family drinking practices and isolation (Institute of Medicine, 1990).

Supporting the contention that non-traditional treatment approaches hold more promise, the Community Older Person's Assistance (COPA) project (Graham et al., 1995) positively evaluated treatment for seniors with the following features:

• outreach - counsellors went to the client's home;
  
• lack of confrontation - admitting to having a problem was not a necessary part of treatment; and
  
• holistic - the overall focus of COPA was on quality of life and maintaining independent living.

The approach was flexible and client-centred, involving any or all of the following: counselling and crisis intervention for the older substance abuser, advice and counselling for the family, and advocacy and coordination with other agencies on the client's behalf.

The evaluation indicated this approach to be very effective in engaging clients in treatment. About three quarters of the participants experienced at least some improvement and this tended to be stable over time.

Best Practice Guideline (No. 16)

Seniors are often reluctant to acknowledge a substance use problem or to seek help from specialized services. Community-based treatment provided in the broader context of support for health and the activities of daily living, using a client-centred, flexible and holistic approach, is more effective.

e) Clients with Concurrent Mental Health Problems

Clients in mental health treatment consistently show higher rates of alcohol and other drug consumption and related problems than the general population. Persons with severe mental illness are particularly at risk for substance abuse. According to the Epidemiological Catchment Area Study in the United States (Regier et al., 1990) which assessed psychiatric and substance abuse disorders in over 20 000 people in the community and various institutional settings, those with schizophrenia and bipolar disorder were respectively four times and greater than five times more likely to have had a substance abuse disorder in their lifetimes than persons in the general population.

In a review on treatment for co-occurring substance abuse and mental illness, Meuser, Drake and Miles (1996) found those with severe mental illness and co-occurring substance abuse to be more likely to exhibit:

• increase in relapse and rehospitalization rates;
  
• increase in depression, suicide and violence;
  
• greater housing instability and homelessness;
  
• non-compliance with medications and other treatments;
  
• increased vulnerability to HIV infection;
  
• increased family burden; and
  
• higher service utilization and costs.
  
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Substance abuse problems among persons who are mentally ill are more likely to be associated with such issues as money management and stable housing, and less likely to be issues that show up on standard assessments for substance abuse. Even when they are well engaged with mental health treatment, dually diagnosed clients tend to be in a pre-motivated state regarding their substance abuse (Meuser, Drake and Miles, 1996).

Follow-up studies of clients treated in either addictions or mental health treatment show uneven results. Remission of untreated co-occurring disorders appears to be common, but there are instances where rates of co-occurring problems remain unchanged despite a positive effect on the treated disorder. There is currently little empirical basis for predicting one result or the other (ARF, 1997).

At the same time, substance abuse can influence the course of treatment for mental health problems, while co-occurring psychiatric problems can have an impact on addictions treatment. In some studies, patients in addictions treatment with less severe psychiatric problems showed greater improvement than those with more severe psychiatric symptoms. Clients with mental health problems that remain unaddressed may also be more prone to dropping out of treatment (ARF, 1997).

Because clients with concurrent disorders have a range of other social and physical problems, those who do receive care tend to use multiple services (Wooghe, 1990). The available epidemiological data on service utilization suggest that those reporting co-occurring disorders are more likely to receive services from the general health care system, and from the social services and criminal justice systems, than from specialized addiction or mental health services. Thus, these systems should be brought into any strategy intended to effectively address this issue (ARF, 1997).

Systems level concerns, such as fragmentation of services, inadequate or inappropriate referrals and a lack of service coordination, are often cited in relation to these co-occurring disorders. Traditionally, substance abuse and mental health problems have been treated in separate facilities, and this has resulted in clients with concurrent disorders "falling between the cracks" or bouncing back and forth between treatment facilities which do not adequately meet their complex and multiple needs. So, much of the literature on dual diagnosis is concerned with the coordination of identification, assessment and treatment services to best manage both the mental health and substance use problems. Clinical issues include which disorder should be regarded as primary, the role of psychotherapy, which disorder should be treated first, whether it is possible to treat both disorders at once, the role of medications and whether one disorder produces symptoms of the other (ARF, 1997; el-Guebaly, 1993).

These challenges have led service providers to recommend a range of different treatment options, from the provision of specialized programs to the coordination or amalgamation of existing services. Three basic models for treating dual substance abuse and mental disorders are mentioned in the literature: sequential treatment, parallel treatment and integrated treatment (Ries, 1993). While research is limited, outcomes for clients treated sequentially or in parallel have been poor. Recent efforts to address co-occurring disorders have focused on integrating the services and providing them simultaneously. Integrated models of service typically share the following features:

• assertive outreach to engage people in treatment and to address pressing social or clinical concerns;
  
• case management;
  
• group interventions (e.g. social skills training);
  
• focus on increasing motivation for treatment;
  
• promote a long-term perspective recognizing the chronic nature of conditions; and
  
• often use behavioural strategies, work with families and time interventions according to readiness to change.
  
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While integrated treatment needs to be further studied, preliminary studies on a range of different integrated treatment models are suggesting better outcomes than those produced by parallel approaches. The New Hampshire Dual Disorders Study compared the effects of two different integrated case management methods for providing treatment to 240 clients. Preliminary analysis indicates that both approaches were effective in reducing substance abuse and improving other outcomes (Meuser, Drake and Miles, 1996).

The Addiction Research Foundation (1997) proposed, among other recommendations, the following measures to improve services for people with co-occurring disorders:

• Initiatives to improve referral and coordination between existing specialized services should be undertaken and evaluated for their effects and cost-effectiveness. These should include models of case management between existing addictions and mental health agencies.
  
• Agency exclusion criteria (i.e. excluding people with mental health problems from addictions treatment or those with alcohol or drug problems from mental health treatment) should in general be disallowed, except where a compelling knowledge-based or practical rationale can be shown.
  
• Training in proven methods for assessing, referring and treating co-occurring disorders should be a priority for professionals in both the specialized addictions and mental health treatment systems.
  
• Primary health care providers and staff in disability, social support and criminal justice agencies should also receive training in assessing, referring and treating both addictions and mental health problems.
  

Both of the above-mentioned reports note that this approach should not serve to de-emphasize the specialized services, which they see as essential, particularly in the treatment of more advanced and complex problems. Rather, the intent is that this combination of addiction-specific services and those within the generic settings would together form an accessible "continuum of care."

Best Practice Guideline (No. 17)

While evidence is limited, it appears that providing integrated services for people with co-occurring substance use and mental health problems holds more promise than offering services in sequence or parallel. Close liaison and coordination to enhance referral and case management need to occur among the respective specialized services and informal street-level agencies in a community. Training appears crucial, not only for staff of respective specialized services, but also for social services and correctional staff where these clients often present themselves. Excluding people with mental health problems from addictions treatment and excluding those with alcohol or drug problems from mental health treatment should, in general, be discouraged.

f) Clients Living with HIV/AIDS

Injection Drug Use (IDU) has been an increasingly important route of transmission of HIV in Canada, with 19.9% of adult cases diagnosed with AIDS in 1997 attributed to IDU transmission (Health Canada, 1998). At the time of writing, Vancouver has the highest rate of HIV infection among injection drug users in North America. Populations at particular risk of AIDS attributable to IDU are Aboriginal people and women. Aboriginal people are over-represented among urban injection drug users and in correctional institutions which are understood to be high-risk settings for injection drug use and HIV/AIDS.

Although several reports have been released in Canada on this issue, there exists little research examining the issue of substance abuse treatment for people living with HIV/AIDS (PLWAs).

The results of one study were released in April 1996 by "The Point Project" (Archibald et al., 1996), a project designed to examine the risk factors for HIV infection among IDUs living in Vancouver. This study's sample included a total of 89 HIV-positive and 192 HIV-negative persons. Results indicated an increased severity of drug problems (cocaine and heroin) among HIV-infected persons arising from decreased control over their living environments and a relative inability to make positive decisions regarding their health. Resulting recommendations included the implementation of an accessible substance abuse treatment program for injection drug users; research into the effectiveness of methadone maintenance treatment programs among injection drug users living in Vancouver; and the provision of more treatment options, emphasizing harm reduction.

A substantial barrier to the use of drug treatment and rehabilitation services by PLWAs is the fact that services often do not know how to deal with these two problems together. The approach of substance abuse treatment services can conflict with the perspective of street-involved injection drug users. Substance abuse professionals tend to possess inadequate knowledge of the treatment of PLWAs, just as professionals trained in counselling PLWAs tend to lack sufficient knowledge in the area of substance abuse.

Improvements to substance abuse treatment for persons with AIDS were recommended by British Columbia's Medical Health Officer in a report entitled Health Impact of Injection Drug Use and HIV in Vancouver (Whynot, 1996). This report recommended the following treatment measures for PLWAs:

• the implementation of regional substance abuse programs for IDUs within the Vancouver area, emphasizing both addiction management and drug abstinence alternatives;
  
• the development of partnerships by the College of Physicians and Surgeons toward the implementation of a more accessible system of methadone maintenance treatment in Vancouver and the implementation of other methods of addiction symptom management;
  
• the development of mental health services and counselling for injection drug users;
  
• the development of a working group within British Columbia to investigate methods of addiction symptom management for cocaine users and to develop alternatives to methadone maintenance treatment;
  
• that university teaching hospitals within the Vancouver area develop an addiction management strategy.
  

In 1991, the Addiction Research Foundation (ARF) prepared a document entitled Best Advice: Prevention Strategies - Injection Drug Users and AIDS (ARF, 1991). This paper stresses the importance of increased access to drug addiction treatment services for PLWAs, including increasing the number of methadone maintenance treatment programs available in Canada.

Also, through the Canadian Strategy on HIV/AIDS, Health Canada has developed a resource entitled Care, Treatment and Support for Injection Drug Users Living with HIV/AIDS (1997). Suggested support services recommended by this report for IDUs infected with HIV/AIDS include needle exchange programs; the use of street clinics and nurses in the provision of primary care, counselling and support; social support systems to supplement basic needs such as food and clothing; and increased access to substance abuse treatment and rehabilitation programs and supportive housing establishments.

Many IDUs spend time in prison settings. Injection drug use in prisons has contributed to a critical situation in Canada's prisons where the rate of HIV infection has increased dramatically in recent years. Unfortunately, responses by federal, provincial and territorial correctional services to deter the spread of HIV within this population have been sporadic. Some prisons now distribute bleach to disinfect needles; however, the use of this safeguard in Canadian prisons is uneven. Similarly, there also seems to be few resources allowing HIV-infected drug users to access appropriate treatment for their substance use.

A Task Force on HIV/AIDS and Injection Drug Use released a national action plan which contains 15 key recommendations addressing the multiple difficulties of a drug user with HIV or AIDS obtaining appropriate, accessible treatment (Canadian Centre on Substance Abuse and Canadian Public Health Association, 1997). A central theme is the Task Force's call to increase access to care and treatment options by reducing the stigma attached to this issue. Examples include eliminating the requirement for total abstinence from drug use before receiving drug or HIV treatment, and ensuring each individual is offered antiretro viral medication, even if currently using illegal drugs. Reflecting a harm reduction priority, the task force recommended that the availability of methadone maintenance treatment be increased dramatically and that clinical trials of prescription morphine, heroin and cocaine be conducted in this country.

Best Practice Guideline (No. 18)

Injection drug users with HIV/AIDS tend to be very marginalized in their communities, and it is difficult for them to access appropriate care and treatment. The very considerable health risks facing this population call for better coordination of services and more innovative treatment measures to reduce this harm, particularly among Aboriginal people, women and those in prison settings.

Best Practice Guideline (No. 19)

Special populations need improved access to treatment through some combination of: greater awareness of and access to informal help such as self-help/mutual aid groups and self-instructional material; greater involvement of general community services in identifying and supporting clients with substance abuse problems; and, provision of specialized services through outreach efforts. Effective case management is particularly important to meet the unique and often multiple needs of these clients.