Philip A.M. Rogers MRCVS

AP in Detoxification / Withdrawal


ASAP (1996) AP in a Drug & Alcohol Detoxification & Treatment Program. Adapted from WWW. Contact: Alternative Substance Abuse Program, 612 Colorado Blvd., Suite 115, Santa Monica, CA 90401 USA; Tel: (310) 452-1011. AP has been successful in detoxification in both clinical settings and under controlled experimental conditions. The results of a 1-yr AP detoxification study in Portland, Oregon and a blind study of AP treatment with chronic alcoholics in Hennepin County, Minnesota are: People who received AP detoxification treatment were 2 times more likely to continue in rehabilitation therapy than people who did not receive AP treatment. >70% of people treated with AP successfully completed detoxification, compared with only 50% of hose who did not receive the treatment. For those detoxifying from alcohol, the success rate was 90%. Recidivism (relapse rate) of addicts to alcohol or drugs fell from 20-25% to 5% for patients receiving AP detoxification treatments. In a blind study of chronic alcoholics in Hennepin County, 37% of the treatment group receiving AP completed the program. Only 7% of the control group had a successful completion of the program.

Avants_SK; Margolin A; Chang P; Kosten TR; Birch S (1995) AP for the treatment of cocaine addiction. Investigation of a needle puncture control. J Subst Abuse Treat May-Jun 12(3):195-205. Yale Univ Sch of Med, CMHC/Substance Abuse Centre, New Haven, CT 06519, USA. This was a 6-wk, single-blind study of AP for cocaine dependence in methadone-maintained patients (N=40) to identify an appropriate needle puncture control for use in future large-scale clinical trials. Patients were randomly assigned to 2 groups: 1=AP daily at 3 Earpoints, plus LI04 and; 2=AP at non-AP points <2-3 mm away from the 4 active sites. Overall, both treatments gave a positive response in many drug-related and psychosocial measures. Cocaine use decreased significantly for patients in both groups. The only statistically significant difference between the two groups was on ratings of craving. Subjects rated each type of needle puncture as equally credible and perceived no significant differences on the acute effects of the two types of needle insertions. Power calculations suggested that very large sample sizes would be required to detect treatment differences between active AP points and placebo control points <2-3 mm away from them. Alternative controls are suggested, and the challenges inherent in implementing controlled clinical trials of AP are discussed.

Brewington_V; Smith M; Lipton D (1994) AP as a detoxification treatment: an analysis of controlled research. J Subst Abuse Treat Jul-Aug 11(4):289-307. Lincoln Med and Mental Health Centre, Bronx, New York 10454. The research literature on the use of AP as a substance abuse treatment is reviewed. Recently, many reports have been published on the efficacy of AP in alleviating withdrawal symptoms with substance abusers attempting abstinence. While few experimental design studies have been done in this area, results from controlled studies generally support that AP is effective in assisting active drug and alcohol users to become abstinent. Controlled, experimental research on AP and related techniques used as substance abuse treatments are reviewed. An overview regarding AP and related procedures used as substance abuse treatments is first provided. Animal and human studies on AP's usefulness in alleviating opiate withdrawal symptoms are presented, followed by studies concerning other substance abuse problems (i.e, alcohol, tobacco and cocaine). Possible physiological mechanisms related to AP's effects are reviewed.

Brumbaugh_AG (1993) AP: new perspectives in chemical dependency treatment. J Subst Abuse Treat Jan-Feb 10(1):35-43. Council on Alcoholism and Drug Abuse, Santa Barbara, CA 93102. The use of Ear-AP in treating acute drug withdrawal began in Hong Kong in 1972. Its practical application in the traditional drug treatment setting evolved at New York City's Lincoln Hospital during the 1970s, and over 250 AP programs in diverse treatment settings have since been established world wide, based on the Lincoln protocol. AP treatment offers the client support during acute and postacute withdrawal through relief of classic symptoms. It has also been found useful as an entry point to treatment and/or recovery in such non-treatment settings as jails and shelters, and has particular efficacy to treat resistant clients, and of prepartum and postpartum women. Though chemical-dependent society accepts the validity of AP with reservation, both research and outcome studies indicate that AP holds promise as a complement to traditional modalities used to counter substance abuse.

Johnstone_H; Marcinak J; Luckett M; Scott J (1994) An evaluation of the treatment effectiveness of the Chicago Health Outreach AP Clinic. J Holist Nurs Jun 12(2):171-183. AP is a treatment modality that is particularly applicable for homeless clients because of its low cost and portability as well as because of its effectiveness in treating the symptomatology of pain syndromes, substance abuse, and human immunodeficiency virus infection. A 2-part descriptive study was conducted to determine the response to AP of homeless persons at the Chicago Health Outreach Clinic. Part 1 of the study consisted of a retrospective chart review of 45 patients to assess AP treatment effectiveness. Part 2 of the study consisted of using a numerical rating scale report form to assess treatment effectiveness of 30 patients. Part 1 of the study indicated that 51% had a positive response to treatment, 42% were indeterminate or lacked documentation of response, and 7% had no response to treatment. In Part 2, 97% had a positive response to treatment, with 3% reporting no response to treatment. AP treatment effectively decreased the symptomatology of the homeless clients seen in the Chicago Health Outreach AP Clinic. Further research should involve follow-up of these clients to assess the length of symptom relief to further determine long-range effectiveness and cost of treatment.

Konefal_J; Duncan R; Clemence C (1994) The impact of the addition of an AP treatment program to an existing metro-Dade County outpatient substance abuse treatment facility. J Addict Dis 13(3):71-99. Dept of Psychiatry, Univ of Miami Sch of Med, FL 33136, USA. Several types of treatment facilities and modalities can deal with substance abuse. In this study, the addition of AP treatments to the usual care program at an existing county-based substance abuse treatment clinic was tested. Men and women who voluntarily attended the clinic or who were remanded by the court to attend were randomized to receive usual care, usual care plus frequent urine testing, or usual care plus frequent urine testing and AP treatments. Clients who received AP, in addition to the usual care and frequent urine testing, became clean (as measured by negative urine tests) in 57% of the time required for the frequent urine testing group. Difficulties experienced included low counsellor compliance with the protocol and a high drop-out rate, indicating that further research is necessary. The study shows that AP can be a feasible and effective addition to existing drug treatment programs.

Lipton_DS; Brewington V; Smith M (1994) AP for crack-cocaine detoxification: experimental evaluation of efficacy. J Subst Abuse Treat May-Jun 11(3):205-215. Nat Development and Research Inst Inc., New York, NY, USA. Anecdotal studies have reported AP alleviating the severity of withdrawal symptoms associated with cocaine abuse. The efficacy of Ear-AP in reducing cocaine/crack craving and consumption was examined via a single-blind, placebo experiment. 150 people seeking treatment for cocaine/crack abuse were randomly assigned to two treatment groups to receive either: 1=Experimental AP, or; 2=Placebo AP. Treatments were provided in an outpatient setting for 1 mo. Placebo treatments involved AP at Earpoints not used for drug treatment. Subjects provided urine specimens for drug content analysis after each AP session. Urinalysis results over the 1-mo study period favoured the experimental group. Experimental subjects in treatment over 2 wk had significantly lower cocaine metabolite levels relative to placebo subjects in treatment for a comparable period. Treatment retention with both groups was similar. Relative to pretreatment usage, a significant decrease in cocaine consumption was reported by both groups. Self-report outcomes did not indicate significant between-groups differences.

Margolin_A; Chang P; Avants SK; Kosten TR (1993) Effects of sham and real Ear-needling: implications for trials of AP for cocaine addiction. AJCM 21(2):103-111. Dept of Psychiatry, Yale Univ Sch of Med, New Haven, CT 06519. This was a single-blind study (n=48) to compare subjective evaluation of needling sham and real Ear-AP points. Both ears were needled concurrently, one in sham sites and the other in active points used to treat cocaine addiction. Subjects then completed a questionnaire rating the intensity of 5 sensations in each ear, and also attempted to identify which ear received sham and which ear received real AP. Real points were more painful than sham; there were no other overall differences. Subjects' ability to identify which ear received sham and which ear received real AP did not rise above the level of chance.

McLellan_AT; Grossman DS; Blaine JD; Haverkos HW (1993) AP treatment for drug abuse: a technical review. Pennsylvania VA Centre for Studies of Addiction, Philadelphia. J Subst Abuse Treat Nov-Dec 10(6):569-576. Pennsylvania VA Ctr for Studies of Addiction, Philadelphia, PA. The efficacy of AP for the treatment of substance abuse is controversial. On October 23, 1991, the Nat Inst on Drug Abuse (NIDA) sponsored a technical review to discuss this issue. The purpose of the meeting was to review the current status of research regarding AP treatment for drug abuse and to propose directions for future studies. This report represents a summary of the meeting which consisted of presentations by individuals currently involved in AP treatment and discussions by a panel of experts in the field of substance abuse treatment research.

Miller_J (1996) An Evaluation of an AP Program for Drug Treatment in San Diego County. Adapted from WWW. A recent pilot study was by the City of San Diego aimed to determine whether or not AP helped to curb the drug addictions of patients and/or motivated these parolees to search for a higher quality of life without drugs. The hope was to find if AP will ease the patients through the initial stages of Post Acute Withdrawal Syndrome (emotional, psychological, and physical symptoms of ridding the body of the substance) and to keep them in treatment longer. The Solutions program began AP treatments on September 1, 1993. The focus of this research was to examine the use of AP in an outpatient program for parolees with drug problems.

The outpatient program, funded by the San Diego County Alcohol and Drug Services and operated by the Community Connection Resource Centre receives referrals from the Parolee Partnership Program (PPP). The Pacific Coll of Oriental Med supplies a licensed acupuncturist and required supplies through an agreement with Community Connection. The goal of Community Connection's AP program is to retain outpatient parolee clients in treatment longer than drug-addicted parolees who do not receive AP.

The research procedures included the case tracking of 52 AP clients and a comparison group of 64 individuals in treatment without AP. Information was compiled on the sociodemographic features of the 2 groups: type, level, and history of drug use, and arrests, charges filed, and dispositions during the time in the program. Study results indicate that AP may have an influence on the length of time in treatment and reduce or eliminate drug use. This research may be helpful to treatment providers and policy-makers in determining how best to allocate resources toward populations in treatment and what results can be reasonably expected by using AP. The research suggests areas for future study, such as drug abuse, including criminal behaviour pre- and post- treatment, and cost of treatment compared to the benefits of treatment. The Test Groups: 2 groups were observed: one group received AP treatment and the other group did not, serving as a comparison group. All clients were adult parolees and >80% were male. Both test groups were mainly comprised of Caucasians and African-Americans. Nearly half (46%) of both groups were between the ages of 31 and 40 yr, and roughly a quarter were in the age category of 26 and 30. 2% of each group had a Coll degree while 56% of the AP clients had graduated high school, compared to 47% of the comparison group.

Over one quarter (27%) of the AP clients did not graduate high school compared to 41% of the comparison group. Heroin was cited most often as the primary drug problem by clients in both groups. 36% of the comparison group reported cocaine compared to 23% of the AP group. 56% of the AP clients and 45% of the comparison group stated that injection was their main way to take drugs. 69% for the AP clients and 61% for the comparison group reported no use of their primary drug in the 30 d before treatment admission. Findings: Arrests during the program were few for both groups. Only 4 AP clients were rearrested during their time in treatment; the comparison group had 5 people rearrested. AP clients stayed in treatment nearly twice as long as the comparison group (a mean of 93 d for the AP clients compared to a mean of 48 d for the comparison group.) Also, the AP clients received more individual counselling, group counselling, ancillary services, and employment referrals than the comparison clients.

Clients had a mean of 10 sessions of AP treatment. Successful AP clients spent a mean time in the program almost double that for successful comparison clients (113 d versus 70 d, respectively). 90% of the AP clients, compared to 69% of the comparison group, reported no drug use since the beginning of the treatment program. 33% of the AP clients were employed in the beginning of treatment, and by the end of treatment, 65% were employed. While the comparison group also show an increase in employment upon program completion, the total number of comparison clients employed upon exit was less (43%). Interpretations: The entire outpatient program lasts 180 d, but, in the past, most people only attended between 30 and 60 d. AP clients stayed in treatment nearly twice the amount of the comparison group (a mean of 93 d for the AP clients and mean of 48 d for the comparison group). Therefore, AP clients had greater opportunity to receive additional individual counselling, group counselling, and ancillary services.

Each client received a mean of 10 AP treatment sessions. Based on a mean of 3 mo in treatment, each received almost one AP session/wk. The goal of the AP component of Solutions program was to keep parolees in treatment longer so they could benefit from the services provided. As noted above, the AP clients did spend more time in treatment and, although self-reported, 90% claim they did not use drugs during their treatment. Some of the factors that impede treatment efforts were that many of the parolees who entered the Solutions program either did not volunteer to receive AP treatment or did not complete the treatment program.

According to the Solutions staff, the reactions to treatment and the reservations toward participating included fear of needles, fear of a new dependence on the AP, headaches or fatigue resulting from treatment, or no positive experiences due to AP (e.g. relaxed, attentive at group therapy, less stressed, etc). Most individuals in either group did not stay in treatment for the recommended (180 d) which is an issue that the service provider may wish to address along with the fact that Solutions' clients did not receive as many AP treatments as specified in the program scope of work. Further information: The results of this pilot study have been so well received by the San Diego substance abuse treatment community that plans are currently under-way for inclusion of AP treatment at San Diego's Las Colinas Women's Detention Facility and the Otay Mesa Jail. Acupuncturists interested in working in these facilities should send their resume to Pacific Coll, attention Jack Miller.

Oleson TD (1996) Addictive Behaviours and Drug Detoxification with Ear AP. Adapted from WWW. Terry Oleson PhD.
The points listed on this page represent a small part of a large book called Auriculotherapy Manual: Chinese and Western Systems of Ear AP, 2nd Edition. To locate the points specific to these treatments, please see the following 3 images:

Ear Points (148k).

For images that describe the Ear-therapy points for many other conditions, please see: Auricular Microsystem Points (200k).

Points labelled with the letter "C" belong to the Chinese system of AP point locations.
Points labelled with the letter "F" belong to the French system of AP point locations.
The efficacy of these systems versus the system for point location that Dr Oleson illustrates in his book must be determined by the practitioner and the patient.

PP: means "Primary Points".
SP: means "Secondary Points".

PP: Alcoholic Point, LV, LU 2, Brain.C, Point Zero, Shenmen, Occiput, Forehead.
SP: Autonomic Point, Endocrine Point, Tranquillizer Point, Master Cerebral, Thirst Point, External Genitals.C, External Genitals.F, Minor Occipital Nerve, Limbic System, Aggressivity, Master Oscillation, Anti-Depressant Point.

Drug Addiction
PP: LU 2, Point Zero, Shenmen, Autonomic Point, LV, KI.C, Brain, Limbic System.
SP: Occiput, Adrenal Gland.C, External Genitals.C, External Genitals.F.

Nervous Drinking
PP: Alcoholic Point, Thirst Point, KI.C, Brain.C, Shenmen, Nervousness.
SP: Point Zero, Endocrine Point, Thalamus Point, Master Cerebral, Master Tranquillizer.

Smoking Withdrawal
PP: Nicotine Point, LU 1, LU 2, Point Zero, Shenmen, Autonomic Point, Brain.C, Limbic.
SP: Mouth, Palate.C, Palate.F, Adrenal Gland.C, Adrenal Gland.F, Aggressivity. (Treat LU 1 and 2 points at 80 Hz for 2 min).

Weight Control
PP: Appetite Control, Mouth, Oesophagus, ST, SI, Shenmen.
SP: Point Zero, Thalamus Point, Master Sensorial, Master Cerebral, Anti-Depressant Point, Endocrine Point, Posterior Hypothalamus, Occiput. (Treat Appetite Control Point at 20 Hz for 2 min.).

Terry Oleson PhD is a lecturer in Ear-therapy. Receiving his PhD in Psychobiology form the Univ of California at Irvine in 1973, he went on to do pioneering research on Ear-diagnosis and Ear-therapy at the UCLA Pain Management Centre in Los Angeles, California. Besides being the author of many scientific articles, Dr Oleson is the Chair of the Dept of Psychology and the Division of Behaviour Med at the California Graduate Inst. Dr Oleson also serves on the faculty of Emperor's Coll of Traditional Oriental Med and as President of the Centre for Oriental Med Res & Educ (COMRE).

His book, Auriculotherapy Manual: Chinese and Western Systems of Ear AP is available through:

Health Care Alternatives.
8033 Sunset Blvd. #2657.
Los Angeles, CA 90046 USA
Phone (213) 656-2084.
Fax: (213) 656-2085

Smith_MO1 (1989) AP Treatment for Drug Addiction: Testimony presented by Michael O Smith MD DAc, to the Select Committee on Narcotics of the US House of Representatives July 25. Adapted from WWW, NADA Home Page.
I am a physician and psychiatrist who has learned AP on the job as Med Director of the Substance Abuse Division, the Dept of Psychiatry of Lincoln the South Bronx. I completed residency at Lincoln and then worked for their outpatient methadone detoxification program beginning in 1972. I was initially sceptical that such an apparently delicate process such as AP could have a real impact on drug addiction. However, 15 yr of large scale clinical experience has persuaded many of us of the popularity and effectiveness of AP treatment. Currently 250 detoxification patients receive AP daily at Lincoln. Our program provides AP treatment in a large community room where most patients seem to be relaxing or meditating. Each day 45-50 women bring infants and small children with them to our clinic. Typically, the young mother will sit with a baby in her lap while receiving AP.

AP is a foundation for psychosocial rehabilitation so that counselling, drug-free contracts, educational and employment referrals, and Narcotics Anonymous are essential parts of the program. AP not only controls withdrawal symptoms and craving, but it also reduces fears and hostilities that usually disturb drug abuse treatment settings. AP has a balancing effect on the ANS and neurotransmitter systems as well as an apparently rejuvenating effect. Drug abuse treatment is accomplished by inserting 3-5 AP needles just under the skin or surface of the external ear. Needles are sterilized by autoclave. The location of ear points and the technique of insertion can be taught easily so that most AP components can be staffed by a wide range of substance abuse clinicians. Chapter 663 of the laws of New York State was passed in 1988 to establish that AP given in a State-Approved Drug Treatment Program will be exempt form normal licensing, provided that proper training and supervision take place.

Alliance with Criminal Justice System
In January, 1987, our clinic population was suddenly transformed by the avalanche of cocaine-based "crack"that continues to threaten our lives. We have all read of the bizarre, intractable nature of crack addiction. In professional meetings we have been told that the craving and fearful cycles of crack have no known treatment. From the beginning our experience at Lincoln has been strikingly different than these reports.

8,000 crack patients have been treated at Lincoln, many more patients than have been seen at any other program. Crack abusers seek treatment earlier in the course of their illness than other addicts. They often have a longer history of prior drug-free status than other abusers.

We have developed a protocol that is specifically intended to serve criminal justice clients rather than merely grafting probation and parole-referred clients onto a treatment structure designed for voluntary walk-in clients. I believe our program has had the highest success ever recorded to treat an unscreened court mandate population seen on an out patient drug-free basis. >50% of these clients have provided negative urine toxicologies for >2 mo. We have received no adverse reports on these individuals. Certainly, the Lincoln hospital AP Program has the best record in New York City to treat court referred crack abusers.

A computerized tracking system was set up with the assistance of Dr Stan Altman of Stony Brook (SUNY) so that any client's urine testing record could be located at a moment's notice. Lincoln tests urines for cocaine and heroin on a daily basis with EMIT system located on the premises. Therefore a probation officer, for instance, can receive a substantial, precise, and up-to-date report on any client with one phone call. This system is much more appropriate than written correspondence for the hectic and often chaotic work pattern in criminal justice service agencies. Staff members from probation, parole and family court often call for status reports. They also visit the Lincoln clinic and may have a joint session with the client and Lincoln counsellor on such an occasion. Our clients exhibit considerable confidence in this system which allows their frequent toxicology reports to speak for them in court.

55 clients referred by the NYC Probation Dept are listed in our 1987-88 records. Most have received probation with a requirement for drug abuse treatment. Some of our most successful clients have been referred to Lincoln during the pre-sentencing probation investigation. The statistical data can be summarized as follows: 11 of the 55 clients (20%) attended Lincoln only once. 30/44 (68%) of the remaining clients responded to treatment and have provided consistently negative urine toxicologies. This group of 30 successful clients has attended Lincoln for a mean of 9 consecutive wk over >4 mo. The pre-sentencing clients were assigned to probation instead of receiving prison time. One man who was facing 30 yr of federal time for drug-related charges has been sentenced to probation because of his 6-mo record of clean urines. This man still attends NA meetings here every Saturday with his 8-yr-old son. The judges involved have been clearly impressed by our clients' long record of clean urines on an outpatient basis. The successful clients have been re-established. After completing the Lincoln Hospital program, clients often continue long-term drug-free recovery programs, including AA and NA.

A joint project by the NYC Probation Dept, the Police Foundation of Washington, DC and ourselves is under way to provide long term evaluation of Lincoln clients. Our plans include a properly matched controlled study with 2-yr-follow-up of many clients.

In a preliminary study we have traced the outcomes of 34 clients referred to Lincoln by NYC Probation in 1978-88. 6/34 clients (17%) attended Lincoln only once. 18/28 remaining clients (64%) have attended >10 visits over a range of 2-15 mo. Only one of these 18 clients has had his probation revoked and has been sent to prison. 5/18 clients have functioned so well on probation that they were given "early discharges"from the probation system. 5 of the clients who attended <10 times were re-arrested and none were given early discharge. Hence frequent attendance at Lincoln correlates with a 5:1 improvement in outcome for this series of clients.

The possibility of diverting people from incarceration is a very high priority in our field because of overcrowding and the lack of revenue. The National Assoc of Criminal Justice Planners has placed a high priority of AP detoxification in many jurisdictions where crack is rampant.

Smith_MO2 (1989) AP Treatment for Drug Addiction.
Nationwide implementation of this criminal justice program
In April, 1987, I was invited to Portland, Oregon by Judge Nely Johnson and a criminal justice advisor to the mayor. A pilot program was established in the public detox unit.In June the county voted to allow $60,000 of their Federal Bureau of Justice Administration funds to create several AP components. Presently 6 new programs have been established by David Eisen of the Hooper Foundation, the county's contract agency for drug and alcohol treatment. The detoxification program now reports that 85% of its patients complete their program. Before AP was used, only 34% completed the program. The 6-mo recidivism rate has dropped from 25% to 6%. The Oregon State Dept of Correction has helped establish a Criminal Bed Reduction Program using AP to treat men charged with drug and alcohol-related offenses up to the level of class C felony. A clinic for runaway youth and a community-based program have also been started.

State funding is earmarked for AIDS intervention IV drug treatment programs in Portland, Salem and Eugene. AIDS outreach workers will be giving out AP coupons as well as condoms and bleach. The State has suggested a Medicaid reimbursement rate of $28/treatment with an allotment of treatment daily for 3 mo and treatment once/wk for 1 yr. All clinicians will be required to be NADA-certified.

An independent evaluation report prepared by Carolyn Lane for Multnomah County stated: "The successful post-detox enrolment rate is somewhat higher for all AP participants and much higher-nearly double, or 43% versus 25% for participants who had 7 or more treatments. The size of the follow-up group, which is circa 33% of all clients discharged/yr from Hooper Centre, and the lengthy follow-up period of >4 mo, make this finding very impressive.

Our patients were asked, as part of their AP Progress Reports, to note their attendance at self-help recovery groups or their enrolment in other post-detox or recovery programs. Of those that did, circa 2/3 attended Alcoholics Anonymous or Narcotics Anonymous meetings, most 1-2 times/wk but some daily.

Without exception, the clients interviewed were enthusiastic about AP. One "needed less medicine to relax, to sleep,"another felt the desire to use substances "just fade away,"and several remarked they were less tense, less fearful, and "able to cope with things a lot better." Another commented that "with AP, you're moving toward something.".

A major advantage of AP is that treatment can begin immediately, while treatment programs require a client assessment, with its associated costs. The first of these is simply the fixed cost of performing a client evaluation. If the client drops out at this point, as often occurs with unstable individuals, the cost of evaluation plus any potential billing for treatment is lost. Also, the loss is a source of endemic low morale among caseworkers and counsellors. AP treatment does not require such an evaluation and can begin at first contract, in many cases thus retaining clients who would not return otherwise.".

In conclusion, AP appears to be a very cost-effective modality in supplementing and supporting a comprehensive detoxification treatment program. Also, it provides an adjunct treatment that can be applied during the entire cycle of detoxification.".

Judge Herbert Klein of Miami-Dade County has spearheaded the development of an AP-based program in the prison stockade and an outpatient facility in Overton. The program focuses on criminal justice clients; it began in May 1989, and sees 100 people/d.

Suggested reasons for the success of this criminal justice program
1.        AP is a popular and effective treatment. Patients learn to have confidence in daily AP visits and the relief that consistently occurs. AP can treat craving and fear, as well as withdrawal symptoms. This modality facilitates constructive, non-antagonistic counselling and breaks down the barriers that usually inhibit group process. The consistently calm atmosphere in the treatment area is a marked contrast to the tense mood of streets and of even the best conventional drug program. AP acts physiologically by enhancing the patient's own balancing mechanisms. Vitality and integrity is renewed and developed from within before external challenges need to be taken up. In this clinical setting passive aggressive dependency and adolescent acting-out are greatly reduced. Staff and patients alike can focus on stability and growth without the interpersonal static that usually limits communication.

2.        We have applied many of the basic principles of chemical dependency which are often neglected in criminal justice related situations. The struggle for sobriety is "one day at a time." By testing urines daily, providing daily AP, and encouraging brief daily counselling sessions, we are functioning in the same rhythm as the patient's struggle for recovery. Testing urines every 2 wk, in contrast, functions as an external judgmental process that clashes with the potential rhythm of recovery. A common principle of AA is "keep is simple.".

3.        Our clinical staff makes a primary alliance with the criminal justice referral agency as well as with the clients. This process of dual alliance with the client and the disciplinary agency is the basis for successful work in Employee Assistance Programs. The process is not at all contradictory as long as the primary focus is on sobriety and increasing the client's integrity which is the common goal of all parties. Unfortunately many treatment agencies see themselves as adversaries to the courts and end up by disguising the results of sobriety testing and making excuses for continued abuse. This pattern is called "enabling" in our field. The Lincoln clients are very accepting of this "dual alliance" strategy. There is a lack of contradictory messages, a lack of excuses, and an abundance of interest in their daily struggle to be drug-free.

4.        The counselling process at Lincoln emphasizes a non-judgmental, non-invasive supportive approach. The firm challenge of sobriety is established, but the treatment relationship is quite flexible and open-ended. On some days patients may want to "ventilate their feelings each day; at other times they may want to just say, "hello"and take the AP treatment. Patients often experience fear and resentment toward intrusive questions and advice. This phenomenon is particularly true with court-mandated clients. These fears often prevent frequent attendance at otherwise helpful programs. The therapy program cannot "hold a grudge"and put increasing pressure on the patient for previous failures to respond to treatment. Pressure and concern must be appropriate to the quality of today's struggle and not reflect the residue of the past. The use of AP makes this non-judgmental process much easier.

5.        Frequent urine testing provides an objective non-personalized measure of success that can be accepted equally by all parties. In this system, the counsellor is the "good cop" and the urine machine is the "bad cop."

Smith_MO3 (1989) AP Treatment for Drug Addiction. The counselling process can be totally separated from the process of judgment and evaluation. In this approach, clients will not feel a need to be friendly to their counsellor in order to gain a positive evaluation. The computer print-out showing a series of drug-free urines is the only documentation they will need to gain a favourable report for the court.

6.        Clinical supervisors at Lincoln have developed an approach that encourages self-sufficiency in their colleagues. A counsellor who perceives that his or her autonomy is respected will be much more able to develop autonomy in individual clients. The treatment field often neglects the principle that autonomy is a major component of health and sobriety. So much effort is focused on referrals to 24-h facilities that this basic and practical reality often fades out of view. No matter how effective 24-h rehabilitation is, the patient will spend 99% of the time in an independent state. The pressing reality of criminal justice is comparable. To help people, we need to help them function well independently of our agencies.

7. The fear and shame associated with impending incarceration or removal of a child is certainly beneficial for a prospective patient to face a fearful concrete reality. The myth of the well-motivated walk-in patient is just that: a myth. Similarly, court-related referrals should always be made with definite requirements. Referrals of the type "why don't you see if this treatment can help you"lead to an unusually low rate of success. In recent trends of budget deficit and court congestion, the threat of incarceration is often more symbolic than real. The response of probation and SSC clients indicate that a temporary, more-or-less symbolic threat may often be quite effective in persuading a client to begin treatment and these clients continue in treatment long after the circumstances suggesting the threat of punishment abated. This type of situation is typical of interventions and contracting in chemical dependency treatment.

8.        "There is no such thing as a hopeless case" is another basic principle. The Lincoln program does not screen out prospective patients as "poorly motivated" or "unsuitable" as is often done in regard to criminal justice referrals. All referrals are accepted: a fact that makes these statistics all the more promising.

Suggestions for the future
In cooperation with the primary referral sources, Lincoln is developing a selection of treatment contracts that can be mandated for criminal justice clients. For example, a parole client might be required: 1.        to attend AP 5 d/wk for a minimum of 3 wk; 2.        to provide drug-free urines on at least 10 of the first 20 d of treatment; 3.        to provide drug-free urine once/wk for a subsequent 6 mo; 4.        to attend Narcotics Anonymous or equivalent programs for 6 mo.

Note that these requirements allow some leeway in the early period of treatment and continue to require sobriety during the early recovery period. Another client might be mandated to give 6 wk of daily urines and up to a 2-yr follow-up period. Such contracts could easily become the basis of revenue saving court diversion and early release program. Unsuccessful clients would face incarceration, but a sizable number would be spared by their commitment to a drug-free life.

At a recent NYC Bar Assoc retreat, I suggested that drug abusers who are identified by the police sometimes be given summons instead of being arrested. The summons might require that the abuser provide some negative urine toxicologies during a specified period of time in order to avoid arrest. The availability of effective and inexpensive AP treatment for crack abuse makes this type of non-institutional management a legitimate possibility to cope with the huge dimensions of our drug abuse epidemic.

Millions of dollars saved each year by treatment of Crack mothers
One of the bittersweet realities of public service is the opportunity to confront major problems of the day as they develop, much as an explorer discovers new territory and learns to cope with new dangers. Often we are overwhelmed or simply lack methods to handle a given situation. One of the worst symptoms of the crack epidemic has been the massive increase in maternal substance abuse and consequent retention of cocaine-positive infants in hospitals as boarder babies. Many of these infants are deprived of love and nurturing until their mothers can receive successful drug abuse treatment. As virtually the only available outpatient program for crack abuse in the city, Lincoln Hospital has received >3000 referrals of drug-abusing mothers in the past 30 mo. We are pleased to report that the Lincoln Hospital AP Program appears to have saved the city >3 million dollars in 1987 by reducing costs of boarder babies and subsequent foster care for infants born of crack-abusing mothers. The hospital and Special Services for Children (SSC) refer nearly all maternal patients to the AP program. Their attendance and urine results are satisfactory enough so that the agency and the courts release custody of the infants in most cases. Most city hospitals are severely overcrowded and drained of resources due to the boarder baby crisis. Millions of dollars are lost unnecessarily; hospital nurseries are prevented from helping infants with Med needs; and many children remain separated from potentially caring parents. The Lincoln AP program is a reliable alternative to much of the suffering and deprivation of maternal substance abuse.

We sent Dr Wendy Chavkin, then Director of Maternal Health for the City Health Dept, the following reports describing 290 postpartum women whose babies were held in the hospital because of a positive cocaine toxicology. 70% of all postpartum referrals interviewed by our staff have attended AP treatment and counselling on a regular basis for at least 2 consecutive wk. 50% of all referrals have provided a mean of 10 or more clean urines on a regular basis. In one series, postpartum clients provided twice as many clean urines after regaining custody of their child as compared to the pre-custody testing period. These women completed a mean of 3 mo of attendance in our program. 50% of them attend NA meetings. The use of AP detoxification gave substantially beneficial results in this large scale clinical trial.

Special challenges for women in treatment
Lincoln Hospital is the only drug abuse program that I know of which has many child-rearing female clients. Usually female clients in drug programs are rather street-oriented and accommodate to the dominant male clients in that manner. Child-rearing for these women is generally a secondary activity. Lincoln works with many of these street-oriented women. However, a large part of our maternal substance abuse caseload consists of women who identify mainly as home-makers and parents. These women sometimes have outside employment but they almost always have a "job" at home raising children and coping with domestic pressures.

Drug abuse activities invade their home life, but once drug-free status is regained, these women have a respectful "job" they can return to.